A study in this week’s issue of THE LANCET highlights how few critically ill patients in intensive-care units (ICUs) have explicit directives guiding physicians whether or not to resuscitate.
In the absence of explicit directives (eg. from patients or their families), most critically ill patients undergo cardiopulmonary resuscitation by default. In an observational study, Deborah Cook and colleagues from St Joseph Hospital, Hamilton, and researchers in the Canadian Critical Care Trials Group investigated the prevalence, predictors, and procurement pattern of cardiopulmonary resuscitation directives within 24 hours of patients’ admission to ICUs.
2916 patients from 15 ICUs in four countries (Canada, USA, Australia, and Sweden) were recruited to the study. The investigators recorded whether, when, and by whom the patients’ cardiopulmonary resuscitation directives were established, and identified factors associated with a resuscitate or do-not-resuscitate (DNR) directive.
318 (11%) of patients had an explicit resuscitation directive established within 24 hours of ICU admission, and half of those had DNR directives. Just under half the directives (46%) were made by ICU residents (junior ICU doctors). Age strongly predicted DNR directives; patients aged 50-64 years were three times more likely to have a DNR directive; patients aged 65-74 were four times more likely, and patients aged over 75 years were around nine times more likely to have a DNR directive than younger patients. DNR directives within the first 24 hours of ICU admission were also more common among patients admitted to the ICU at night and at weekends. Patients who were unable to make their own decision about life-support care were four times more likely to be given a DNR directive.
In an accompanying Commentary (p 1920), Donald Prough from the University of Texas, USA, expresses concern that most specific directives in Cook and colleagues’ study were made by ICU residents, and given the evidence that DNR directives are more common at night and at weekends, he comments: “…One is left with the discomforting thought that directives were most likely to be established by junior physicians who have little previous knowledge of the patient or their social environment and who are under the pressure that accompanies clinical care of a large group of critically ill patients during off-hours.” He concludes: “In summary, Cook and colleagues have contributed a valuable, well-conducted study to the existing publications on compliance with patients’ preferences in decisions on whether to offer life-sustaining therapy. The heuristic value of this report will no doubt result in further studies that clarify appropriate strategies for patients, patients’ families, and physicians as they confront serious illness that could result in death.”
* See also Commentary: ‘Present, rather than, advance directives’ (p 1921)
Contact: Dr Deborah Cook, Department of Medicine, St Joseph Hospital, 50 Charlton Avenue East, Hamilton, OntarioL8N 4A6, Canada; T) +1 905 521 6079; F) +1 905 521 6068; E) debcook@fhs.csu.mcmaster.ca
Dr Donald S Prough, Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX 77555, USA; E) dsprough@utmb.edu
The Lancet