Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2014 Sep;42(9):2042-7.
doi: 10.1097/CCM.0000000000000403.

Do-not-resuscitate status and observational comparative effectiveness research in patients with septic shock*

Mark A Bradford  1 , Peter K Lindenauer, Renda Soylemez Wiener, Allan J Walkey
Affiliations

Do-not-resuscitate status and observational comparative effectiveness research in patients with septic shock*

Mark A Bradford et al. Crit Care Med. 2014 Sep.

Abstract

Objectives: To assess the importance of including do-not-resuscitate status in critical care observational comparative effectiveness research.

Design: Retrospective analysis.

Setting: All California hospitals participating in the 2007 California State Inpatient Database, which provides do-not-resuscitate status within the first 24 hours of admission.

Patients: Septic shock present at admission.

Interventions: None.

Measurements and main results: We investigated the association of early do-not-resuscitate status with in-hospital mortality among patients with septic shock. We also examined the strength of confounding of do-not-resuscitate status on the association between activated protein C therapy and mortality, an association with conflicting results between observational and randomized studies. We identified 24,408 patients with septic shock; 19.6% had a do-not-resuscitate order. Compared with patients without a do-not-resuscitate order, those with a do-not-resuscitate order were significantly more likely to be older (75 ± 14 vs 67 ± 16 yr) and white (62% vs 53%), with more acute organ failures (1.44 ± 1.15 vs 1.38 ± 1.15), but fewer inpatient interventions (1.0 ± 1.0 vs 1.4 ± 1.1). Adding do-not-resuscitate status to a model with 47 covariates improved mortality discrimination (c-statistic, 0.73-0.76; p < 0.001). Addition of do-not-resuscitate status to a multivariable model assessing the association between activated protein C and mortality resulted in a 9% shift in the activated protein C effect estimate toward the null (odds ratio from 0.78 [95% CI, 0.62-0.99], p = 0.04, to 0.85 [0.67-1.08], p = 0.18).

Conclusions: Among patients with septic shock, do-not-resuscitate status acts as a strong confounder that may inform past discrepancies between observational and randomized studies of activated protein C. Inclusion of early do-not-resuscitate status into more administrative databases may improve observational comparative effectiveness methodology.

PubMed Disclaimer

Figures

Figure 1
Figure 1
Hospital procedures and interventions according to DNR status during the first 24 hours after admission
Figure 2
Figure 2
Mortality Discrimination ROC curve for multivariate models with and without early DNR
See this image and copyright information in PMC

Comment in

References

    1. Lu CY. Observational studies: A review of study designs, challenges and strategies to reduce confounding. Int J Clin Pract. 2009 May;63(5):691–7. - PubMed
    1. Concato J. Study design and “evidence” in patient-oriented research. Am J Respir Crit Care Med. 2013 Jun 1;187(11):1167–72. - PubMed
    1. McKee M, Britton A, Black N, McPherson K, Sanderson C, Bain C. Methods in health services research. interpreting the evidence: Choosing between randomised and non-randomised studies. BMJ. 1999 Jul 31;319(7205):312–5. - PMC - PubMed
    1. Lieu TA, Au D, Krishnan JA, Moss M, Selker H, Harabin A, et al. Comparative effectiveness research in lung diseases and sleep disorders: Recommendations from the national heart, lung, and blood institute workshop. Am J Respir Crit Care Med. 2011 Oct 1;184(7):848–56. - PMC - PubMed
    1. La Puma J, Silverstein MD, Stocking CB, Roland D, Siegler M. Life-sustaining treatment. A prospective study of patients with DNR orders in a teaching hospital. Arch Intern Med. 1988 Oct;148(10):2193–8. - PubMed

Publication types

MeSH terms