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Variation in the Rates of Do Not Resuscitate Orders After Major Trauma and the Impact of Intensive Care Unit Environment

Nathens, Avery B. MD, MPH; Rivara, Frederick P. MD, MPH; Wang, Jin PhD; Mackenzie, Ellen J. PhD; Jurkovich, Gregory J. MD

The Journal of Trauma: Injury, Infection, and Critical Care: January 2008 - Volume 64 - Issue 1 - p 81-91
doi: 10.1097/TA.0b013e31815dd4d7
Original Articles

Background: There is an increased emphasis on benchmarking of trauma mortality outcomes as a measure of quality. Differences in approaches to end-of-life care or perceptions of salvageability might account for some of the variability in outcomes across centers. We postulated that these differences in perceptions or practice might lead to significant variation in the use of do not resuscitate (DNR) orders and sought to identify institutional characteristics associated with their use.

Methods: Patients surviving >24 hours and admitted to an intensive care unit (ICU) in one of 68 centers across the United States were identified from a large prospective cohort study of severely injured patients. Independent predictors of a DNR order at both the patient and institutional level were identified using multivariate hierarchical modeling stratified by age <55 or ≥55.

Results: Of 6,765 patients, 7% had a DNR order, of whom 88% died. The proportion of patients in each center with a DNR order ranged from 0% to 57%. Independent patient-level predictors associated with a DNR order were increasing age, preinjury comorbidity burden, severe injury, and organ failure. Institutional predictors of DNR orders differed by age. Care in an open ICU was associated with a DNR order (odds ratio, 1.7; 95% confidence interval, 1.0–3.0) in the elderly, whereas care in a combined medical-surgical ICU (vs. surgical or trauma ICU) was associated with greater likelihood (odds ratio, 2.0; 95% confidence interval, 1.1–4.1) of a DNR order in the young.

Conclusions: DNR orders are relatively common in seriously injured trauma patients, and there is significant variability in their use across centers. Given the institutional characteristics independently associated with DNR status, it is likely that both differences in the ethos of end-of-life care and perceptions of salvageability affect decision making.

From the Department of Surgery (A.B.N.), St. Michael’s Hospital, University of Toronto, Toronto, Canada; Harborview Injury Prevention and Research Center (F.P.R., J.W.), University of Washington, Seattle, Washington; Center for Injury Research and Policy (E.M.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of Surgery, University of Washington (G.J.J.), Seattle, Washington.

Submitted for publication September 28, 2007.

Accepted for publication October 9, 2007.

Supported by a grant (R49/CCR316840) from the National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention and a grant (R01/AG20361) from the National Institute on Aging of the National Institutes of Health. Dr. Nathens is also supported through a Canada Research Chair in Systems of Trauma Care.

Presented at the 20th Annual Meeting of the Eastern Association for the Surgery of Trauma, January 16–20, 2007, Fort Meyers, Florida.

Reprints will not be available from the authors.

Address for correspondence: Avery B. Nathens, MD, 30 Bond Street, Queen Wing, 3-080, Toronto, Canada, M5B 1W8; email:

© 2008 Lippincott Williams & Wilkins, Inc.