Impact of the COVID-19 pandemic on the care of hospitalised patients with do-not-resuscitate orders: a retrospective cohort study
Anthony Nguyen, Ivor Douglas, Anuj B MehtaObjectives
Do-not-resuscitate (DNR) orders limit the use of cardiopulmonary resuscitation but are often interpreted more broadly. During COVID-19 surges, resource constraints may have increased variability in application, potentially affecting patients with DNR orders. We aimed to determine whether admission during COVID-19 surge months in 2020 versus non-surge months was associated with differences in use of life-sustaining treatments among hospitalised patients with DNR orders.
Methods
Using data from five states (Arizona, California, Iowa, Mississippi and New York), we identified non-surgical patients ≥40 years with early-DNR orders (within 24 hours of admission) admitted during COVID-19 surge versus non-surge months in 2020. In this retrospective cohort study, we determined patient-level odds of receiving mechanical ventilation (MV), renal replacement therapy (RRT) or central venous catheterisation (CVC) during COVID-19 surge versus non-surge periods and differences in hospital-level rates of each treatment.
Results
We identified 191 317 (13.3%) patients with early-DNR orders during COVID-19 surges and 149 022 (12.6%) in non-surge periods. Patient-level utilisation of MV, RRT and CVC was higher during surge periods (MV: 7.7% vs 5.9%, RRT: 4.1% vs 3.8%, CVC: 2.4% vs 2.0%) with similar results after accounting for case-mix differences. The range of risk-adjusted hospital rates for CVC and RRT was similar across time periods but higher for MV during surges.
Conclusions
Resource strains did not lead to more restrictive care for patients with early-DNR orders during COVID-19 surges. Rather, higher rates of MV, RRT and CVC during surge periods likely reflect greater illness severity. The increased prevalence of early-DNR orders during surges warrants further investigation.