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Researchers examine implications of early use of DNR orders
for critically ill ICU patients
Most do-not-resuscitate (DNR) orders issued in the intensive care
unit (ICU) are for older, more severely ill patients and are
issued after the patient has been in the ICU for a day or more.
Some DNRs, however, are issued during the patient's first day in
the ICU. A new study shows that about 36 to 38 percent of
patients with DNRs at ICU admission died in the ICU, and 65 to 67
percent died in the hospital. More than 50 percent of those who
received DNRs later in their ICU stay died in the ICU, and more
than 80 percent died in the hospital. The overall percentage of
patients with very long ICU stays (more than 30 days) and
hospital stays (more than 60 days) was smaller among DNR
These shorter stays by ICU patients with DNR orders suggest that
patients who would have died in the hospital anyway did so after
a shorter time period. Their medical outcomes were the same, but
use of high-technology medical resources was lower, explains John
Rapoport, Ph.D., of the University of Massachusetts.
In a study supported in part by the Agency for Health Care Policy
and Research (HS06026), he and coinvestigators used a detailed
database of ICU patients from six ICUs in four U.S. hospitals to
examine conditions under which DNR orders were issued and their
influence on subsequent length of stay.
The decision to limit care for critically ill ICU patients is not
uncommon, and most deaths in the ICU are now preceded by DNR
orders, which are regarded by some as a way to make death more
humane and respect patient autonomy. This study contradicts the
view of some critics that the "do everything" approach until the
very end is standard practice in the United States for critically
ill patients. More than half of the patients who died did so
after care had been limited, concludes Dr. Rapoport.
See "Resource use implications of do not resuscitate orders for
intensive care unit patients," by Dr. Rapoport, Daniel Teres,
M.D., and Stanley Lemeshow, Ph.D., in the American Journal of
Respiratory and Critical Care Medicine 153, pp. 185-190,
Nearly one-quarter of ICU patients with chronic obstructive
pulmonary disease die in the hospital
Chronic obstructive pulmonary disease (COPD) is the fifth most
common cause of death in the United States and is becoming more
prevalent, especially among women. COPD patients frequently are
admitted to an intensive care unit (ICU) because of increased
respiratory compromise without an objectively documented cause
such as pneumonia. Twenty-four percent of these ICU patients die
in the hospital, according to a study supported in part by the
Agency for Health Care Policy and Research (HS07137).
For elderly COPD patients (65 years of age or older) discharged
from the hospital, mortality doubles from 30 percent at discharge
to 59 percent 1 year later. The major risk factor for both
hospital mortality and subsequent death is the development and
severity of nonrespiratory organ system dysfunction. The need for
mechanical ventilation at ICU admission is not a significant
predictor of either short- or long-term outcomes, once other
patient risk factors are considered, notes Michael G. Seneff,
M.D., from the ICU Research Unit at the George Washington
University, who led the study.
The researchers analyzed hospital mortality and 90-day, 180-day,
and 1-year postdischarge mortality for 362 ICU patients admitted
to 42 ICUs with acute exacerbation of COPD. In most cases, the
acute life-threatening components of these exacerbations can be
reversed and short-term death avoided by mechanical ventilation
and other appropriate treatments. However, patients with greater
abnormalities in respiratory system physiology (which reflect
underlying severity of lung disease) who survive hospitalization
are at higher risk of subsequent death.
Details are in "Hospital and 1-year survival of patients admitted
to intensive care units with acute exacerbation of chronic
obstructive pulmonary disease," by Dr. Seneff, Douglas P. Wagner,
Ph.D., Randall P. Wagner, M.D., and others, in the December 20,
1995 Journal of the American Medical Association 274(23),
Changes in reimbursement policies more than changes in
technology have altered the mix of inpatient procedures
During the 1980s, development of new technologies, pressure from
reimbursement mechanisms, and utilization review policies all
contributed to a decline in inpatient use of certain procedures.
Of the 150 most frequent inpatient procedures in 1980, 37 had
declined in use by more than 40 percent as of 1987. In 1980,
these 37 procedures accounted for about 17 percent of all
inpatient principal procedures performed; in 1987 they accounted
for only 5 percent. These are the findings of a study by Sarah Q.
Duffy, Ph.D., of the Maryland State Health Services Cost Review
Commission, and Dean E. Farley, Ph.D., M.P.A., of H.S.S., Inc.,
both formerly of the Agency for Health Care Policy and
According to the researchers, three main factors contributed to
the decline in inpatient use of these procedures. Most important
has been the shift from inpatient to outpatient settings, which
pertains to 33 of the 37 procedures covered in this study. Some
procedures have been replaced by less invasive, more effective
approaches, and others are now considered ineffective by the
medical community and have been largely abandoned.
The rates of decline in inpatient procedures have been
disproportionately large for Medicaid recipients. Medicaid
patients may be unusually good candidates for outpatient
treatment, note the researchers, because they tend to be younger
and less severely ill. Also, Medicaid typically paid a smaller
portion of actual costs for inpatient care in the 1980s (92
percent, compared with 95 to 101 percent for Medicare and well
over 100 percent for most private insurers).
Finally, hospitalized patients were more severely ill in 1987
than in 1980. The overall mortality rate and proportion of
patients with stage 3 or higher disease (characterized by
multiple site and generalized systemic involvement and poor
prognosis) increased almost 50 percent between 1980 and 1987 for
the 37 procedures included in this study.
Hospitals are more efficient than they were in the 1970s, and
they contain sicker, older patients needing costlier treatment
than when many of these cost-containment policies were developed,
note the researchers. They caution that continued squeezing to
promote efficiency may have unforeseen effects on the care of
inpatients and, ultimately, could begin to compromise clinical
The authors used data from AHCPR's Healthcare Cost and
Utilization Project (HCUP-2) for this study. Details are in
"Patterns of decline among inpatient procedures," by Drs. Duffy
and Farley, in the November/December 1995 issue of Public
Health Reports 110, pp. 674-681.
Over 8 percent of hospitalized Medicare patients arrive from
A first-time national estimate shows that 8.5 percent of
hospitalized elderly Medicare patients arrived at the hospital
from nursing homes in 1987. In most cases, these hospitalizations
were for persons who were permanent residents of nursing homes,
according to Marc P. Freiman, Ph.D., of the Agency for Health
Care Policy and Research's Center for Cost and Financing Studies,
and former AHCPR researcher Christopher M. Murtaugh, Ph.D., now
with the Medical Technology and Practice Patterns Institute.
They used data from the 1987 National Medical Expenditure Survey
and 1987 Medicare hospital data to compare hospitalizations of
nursing home patients with those of elderly persons living in the
community. They found that elderly persons with some nursing home
use were 2.5 times more likely to have at least one hospital stay
during 1987 than persons who had not been in a nursing home that
year. And, although they made up less than 7 percent of the total
elderly population, nursing home residents in 1987 received
nearly one-fourth (23.8 percent) of all the hospital care days
provided to elderly persons in that year. Also, the average
hospital stay for nursing home residents was 2 weeks, 56 percent
longer than the 8.9-day average for elderly persons who had not
used a nursing home in 1987.
For more information, see "Interactions between hospital and
nursing home use," by Drs. Freiman and Murtaugh, published in the
September/October 1995 Public Health Reports 110, pp.
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