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
. 2022 Sep-Dec;10(3):192-197.
doi: 10.4103/sjmms.sjmms_141_22. Epub 2022 Aug 22.

Early Versus Late DNR Orders and its Predictors in a Saudi Arabian ICU: A Descriptive Study

Waleed Tharwat Aletreby  1 , Ahmed F Mady  1   2 , Mohammed A Al-Odat  1 , Ahmed N Balshi  1 , Anas A Mady  3 , Adam M Al-Odat  4 , Amira M Elshayeb  1 , Ahmed F Mostafa  1 , Shereen A Abd Elsalam  5   6 , Kriz L Odchigue  7
Affiliations

Early Versus Late DNR Orders and its Predictors in a Saudi Arabian ICU: A Descriptive Study

Waleed Tharwat Aletreby et al. Saudi J Med Med Sci. 2022 Sep-Dec.

Abstract

Background: Practices of Do-Not-Resuscitate (DNR) orders show discrepancies worldwide, but there are only few such studies from Saudi Arabia.

Objective: To describe the practice of DNR orders in a Saudi Arabian tertiary care ICU.

Methods: This retrospective study included all patients who died with a DNR order at the ICU of King Saud Medical City, Riyadh, Saudi Arabia, between January 1 to December 31, 2021. The percentage of early DNR (i.e., ≤48 hours of ICU admission) and late DNR (>48 hours) orders were determined and the variables between the two groups were compared. The determinants of late DNR were also investigated.

Results: A total of 723 cases met the inclusion criteria, representing 14.9% of all ICU discharges and 63% of all ICU deaths during the study period. The late DNR group comprised the majority of the cases (78.3%), and included significantly more patients with acute respiratory distress syndrome (ARDS), community acquired pneumonia (CAP), acute kidney injury, and COVID-19, and significantly fewer cases of readmissions and malignancies. Septic shock lowered the odds of a late DNR (OR = 0.4, 95% CI: 0.2-0.9;P= 0.02), while ARDS (OR = 3.3, 95% CI: 2-5.4;P < 0.001), ischemic stroke (OR = 2.5, 95% CI: 1.1-5.4;P= 0.02), and CAP (OR = 2, 95% CI: 1.3-3.1;P= 0.003) increased the odds of a late DNR.

Conclusion: There was a higher frequency of late DNR orders in our study compared to those reported in several studies worldwide. Cases with potential for a favorable outcome were more likely to have a late DNR order, while those with expected poorer outcomes were more likely to have an early DNR order. The discrepancies highlight the need for clearer guidelines to achieve consistency.

Keywords: Do-not-resuscitate; Saudi Arabia; frequency; intensive care unit; resuscitation orders; timing.

PubMed Disclaimer

Conflict of interest statement

There are no conflicts of interest.

Figures

Figure 1
Figure 1
Patients' enrollment diagram
Figure 2
Figure 2
Percentage of diagnoses in late and early DNR groups: ARDS – Acute respiratory distress syndrome; CAP – Community acquired pneumonia; AKI – Acute kidney injury; MOF – Multi-organ failure; CPR – Cardiopulmonary resuscitation; PE – Pulmonary embolism; ESRD – End stage renal disease
See this image and copyright information in PMC

References

    1. Flannery L, Ramjan LM, Peters K. End-of-life decisions in the Intensive Care Unit (ICU) – Exploring the experiences of ICU nurses and doctors – A critical literature review. Aust Crit Care. 2016;29:97–103. - PubMed
    1. Lin KH, Huang SC, Wang CH, Chau-Chung, Chu TS, Chen YY. Physician workload associated with do-not-resuscitate decision-making in Intensive Care Units: An observational study using Cox proportional hazards analysis. BMC Med Ethics. 2019;20:15. - PMC - PubMed
    1. Monteiro NF, Simões I, Gaspar I, Carmo E. Do-not-resuscitate and treatment limitation decisions – Six years of experience from a Portuguese general Intensive Care Unit. Rev Assoc Med Bras (1992) 2019;65:1168–73. - PubMed
    1. American Thoracic Society. Withholding and withdrawing life-sustaining therapy. Ann Intern Med. 1991;115:478–85. - PubMed
    1. Guidelines for the appropriate use of do-not-resuscitate orders. Council on Ethical and Judicial Affairs, American Medical Association. JAMA. 1991;265:1868–71. - PubMed