1. Alignment of DNR Status with Patients’ Likelihood of Favorable Neurological Survival after In- hospital Cardiac Arrest Timothy Fendler, MD, MS Cardiovascular Diseases Fellow

2. Disclosures Timothy Fendler – none

4. Background JCAHO mandate: discuss resuscitation preferences on admission to all US hospitalsJCAHO mandate: discuss resuscitation preferences on admission to all US hospitals Well-documented preferences fosterWell-documented preferences foster –Open communication –Patient-physician trust –Mutual understanding –Alleviation of stress/uncertainty in the event of cardiac arrest

5. Background DNR discussion are difficultDNR discussion are difficult –Patient-clinican discord  CPR mistakes –Adequate documentation lacking –Lack of validated prediction tool for prognosis CASPRI ScoreCASPRI Score –“Cardiac Arrest Survival Post-Resuscitation In-hospital” –Derived/validated in 42, 957 resuscitated patients

6. Research Question Is DNR status adoption well-aligned with likelihood of favorable neurological survival among survivors of in-hospital cardiac arrest?Is DNR status adoption well-aligned with likelihood of favorable neurological survival among survivors of in-hospital cardiac arrest?

7. Definition of Variables DNR status –DNR order placed within 12 hours after achieving ROSC from an in- hospital cardiac arrestDNR status –DNR order placed within 12 hours after achieving ROSC from an in- hospital cardiac arrest Favorable Neurological Survival – CPC score of 1 or 2 at dischargeFavorable Neurological Survival – CPC score of 1 or 2 at discharge Likelihood of FNS – CASPRI scoreLikelihood of FNS – CASPRI score –Divided cohort into deciles

8. Exclusion Flow Chart

9. Results

10. >3-5 d >24 h-3 d >12-24 h 0-12 h

11. Results

13. Summary DNR and prognosis were generally aligned among survivors of in-hospital cardiac arrestDNR and prognosis were generally aligned among survivors of in-hospital cardiac arrest >2/3 patients with worst prognosis not made DNR>2/3 patients with worst prognosis not made DNR Only 6.3% of these experienced “good survival”Only 6.3% of these experienced “good survival” ~1/10 patients with best prognosis made DNR~1/10 patients with best prognosis made DNR Survival rates 1/10 th of those with best prognosis & not DNRSurvival rates 1/10 th of those with best prognosis & not DNR DNR patients had same LoS & costs, regardless of prognosisDNR patients had same LoS & costs, regardless of prognosis

14. Conclusions Decisions to become DNR among successfully resuscitated patients after in-hospital cardiac arrest are generally aligned with prognosisDecisions to become DNR among successfully resuscitated patients after in-hospital cardiac arrest are generally aligned with prognosis Focus areas for potential improvement include patients with the worst and best prognosesFocus areas for potential improvement include patients with the worst and best prognoses Systematic use of a prognostic tool, such as CASPRI, may optimize DNR decision-making in the in-hospital, post-arrest settingSystematic use of a prognostic tool, such as CASPRI, may optimize DNR decision-making in the in-hospital, post-arrest setting

15. Extra Slides

16. Background The CASPRI toolThe CASPRI tool –Includes 11 variables: Age  Renal insufficiencyAge  Renal insufficiency Initial arrest rhythm  Hepatic insufficiencyInitial arrest rhythm  Hepatic insufficiency Pre-arrest neurological disability  SepsisPre-arrest neurological disability  Sepsis Hospital location of arrest  Malignant diseaseHospital location of arrest  Malignant disease Duration of arrest  HypotensionDuration of arrest  Hypotension Need for mechanical ventilationNeed for mechanical ventilation –Strongly predicts likelihood of favorable neurological survival after in-hospital cardiac arrest C statistic = 0.802 for discriminationC statistic = 0.802 for discrimination

17. Background

18. Background

19. Limitations of Study Occurrence, frequency, & content of DNR discussions unknownOccurrence, frequency, & content of DNR discussions unknown Some DNR decisions may reflect unmeasured confoundersSome DNR decisions may reflect unmeasured confounders Unknown if DNR status adoption is a marker or mediator of worse survivalUnknown if DNR status adoption is a marker or mediator of worse survival