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Do not resuscitate status, not age, affects outcomes after injury: An evaluation of 15,227 consecutive trauma patients

Adams, Sasha D. MD; Cotton, Bryan A. MD, MPH; Wade, Charles E. PhD; Kozar, Rosemary A. MD, PhD; Dipasupil, Edmundo CSTR; Podbielski, Jeanette M. RN; Gill, Brijesh S. MD; Duke, James R. MD; Adams, Philip R. MD; Holcomb, John B. MD

Journal of Trauma and Acute Care Surgery: May 2013 - Volume 74 - Issue 5 - p 1327–1330
doi: 10.1097/TA.0b013e31828c4698
Original Articles

BACKGROUND: Despite a well-described association of age and injury with mortality and decreased functional status, inpatient mortality studies have traditionally not included analysis of do not resuscitate (DNR) status. We hypothesized that the increased likelihood of DNR status in older patients alters age-adjusted mortality rates in trauma.

METHODS: The trauma registry was queried for adult patients admitted to our Level I trauma center (January 2005–December 2008) and divided into eight age groups by decade. Ages 15–44 years were collapsed because of the lack of variation. We compared age, case fatality rate, and DNR status by univariate analysis and trends by χ2 (p < 0.05).

RESULTS: Of the 15,227 adult patients admitted, 13% were elderly (≥65) and 7% died. DNR status was known in 75% of deaths, and 42% of those had active DNR orders on the chart at time of death. DNR likelihood increased with age (p < 0.05), from 5% to 18%. With DNRs excluded, mortality variability across all ages was markedly diminished (4–7%).

CONCLUSION: DNR status among trauma patients varies significantly because of inconsistent implementation and meaning between hospitals, and successive decades are more likely to have an active DNR order at time of death. When DNR patients were excluded from mortality analysis, age was minimally associated with an increased risk of death. The inclusion of DNR patients within mortality studies likely skews those analyses, falsely indicating failed resuscitative efforts rather than humane decisions to limit care after injury.

LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level IV.

From the Center for Translational Injury Research (B.A.C., C.E.W., J.M.P., J.B.H.) and Department of Surgery (S.D.A., B.A.C., C.E.W., R.A.K., B.S.G., J.R.D., P.R.A., J.B.H.), University of Texas Health Science Center; and Memorial Hermann Healthcare System (E.D.), Houston, Texas.

Submitted: November 14, 2012, Revised: January 4, 2013, Accepted: January 7, 2013.

This study was presented at the 70th Annual Meeting of the American Association for the Surgery of Trauma, September 14, 2011, in Chicago, Illinois.

This research was supported by the University of Texas Medical School–Houston and NIGMS funding (grant nos. T-32 GM008792 and P-50 GM38529).

Address for reprints: Sasha D. Adams, MD, Department of Surgery, Division Acute Care Surgery, 4008 Burnett Womack Bldg, Campus Box 7228, Chapel Hill, NC 27599-7228; email: sasha_adams@med.unc.edu.

© 2013 Lippincott Williams & Wilkins, Inc.