Do-not-resuscitate orders in trauma patients may bias mortality-based effect estimates

An evaluation using the PROMMTT study

Charles E. Wade, Deborah J. Del Junco, Erin E. Fox, Bryan A. Cotton, Mitchell J. Cohen, Peter Muskat, Martin A. Schreiber, Mohammad H. Rahbar, R. Michelle Sauer, Karen J. Brasel, Eileen M. Bulger, John G. Myers, Herb A. Phelan, Louis H. Alarcon, John B. Holcomb

Research output: Contribution to journalArticle

8 Citations (Scopus)

Abstract

BACKGROUND: The impact of do-not-resuscitate (DNR) orders has not been systematically evaluated in acute trauma research.We determined the frequency, timing, and impact on mortality-based effect estimates for patients with DNR orders in the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study. METHODS: Trauma patients surviving at least 30 minutes and transfused one or greater unit of red blood cell within 6 hours of admission (n = 1,245) from 10 Level 1 centerswere enrolled.We report descriptive statistics and results from survival analysis to compare the association of blood product transfusion ratios with outcome defined as mortality and as a composite, DNR, and death. RESULTS: DNRs were reported for 95 patients (7.6%), with 94 in-hospital deaths. There were 172 deaths without DNRs. Of 90 known DNR order times, the median was 53 hours (interquartile range, 9Y186 hours) after admission; the median DNR-to-death time was 10 hours (2-32 hours). DNRs were for comfort measures only (43%), no cardiopulmonary resuscitation (40%), and no intubation or cardiopulmonary resuscitation (16%). Compared with the 116 non-DNR deaths that occurred after the earliest DNR order (2 hours), the DNR decedents were significantly older with a less severe base deficit, fewer red blood cell and plasma transfusions, and a later median time of death (98 [21-230] hours vs. 17 [4-91] hours). In multivariable Cox models that accounted for time-varying blood product ratios, the associations were consistent, regardless of whether outcome was defined as mortality or the composite. CONCLUSION: DNR orders were instituted after the 24-hour period of highest mortality risk and more often in older patients not in severe shock. Findings from the primary PROMMTT analyses of the impact of blood product ratios on survival did not materially change when the original mortality outcome was redefined as a composite of DNR or death. DNR orders are potentially an important mediating variable that should be systematically evaluated in trauma research.

Original languageEnglish (US)
JournalJournal of Trauma and Acute Care Surgery
Volume75
Issue number1 SUPPL1
DOIs
StatePublished - 2013

Fingerprint

Resuscitation Orders
Mortality
Wounds and Injuries
Cardiopulmonary Resuscitation
Erythrocyte Transfusion
Survival Analysis
Proportional Hazards Models
Research
Intubation
Blood Transfusion
Shock
Erythrocytes
Survival

Keywords

  • Resuscitation
  • Survival
  • Withdrawal of care

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine
  • Surgery

Cite this

Do-not-resuscitate orders in trauma patients may bias mortality-based effect estimates : An evaluation using the PROMMTT study. / Wade, Charles E.; Del Junco, Deborah J.; Fox, Erin E.; Cotton, Bryan A.; Cohen, Mitchell J.; Muskat, Peter; Schreiber, Martin A.; Rahbar, Mohammad H.; Sauer, R. Michelle; Brasel, Karen J.; Bulger, Eileen M.; Myers, John G.; Phelan, Herb A.; Alarcon, Louis H.; Holcomb, John B.

In: Journal of Trauma and Acute Care Surgery, Vol. 75, No. 1 SUPPL1, 2013.

Research output: Contribution to journalArticle

Wade, CE, Del Junco, DJ, Fox, EE, Cotton, BA, Cohen, MJ, Muskat, P, Schreiber, MA, Rahbar, MH, Sauer, RM, Brasel, KJ, Bulger, EM, Myers, JG, Phelan, HA, Alarcon, LH & Holcomb, JB 2013, 'Do-not-resuscitate orders in trauma patients may bias mortality-based effect estimates: An evaluation using the PROMMTT study', Journal of Trauma and Acute Care Surgery, vol. 75, no. 1 SUPPL1. https://doi.org/10.1097/TA.0b013e31828fa422
Wade, Charles E. ; Del Junco, Deborah J. ; Fox, Erin E. ; Cotton, Bryan A. ; Cohen, Mitchell J. ; Muskat, Peter ; Schreiber, Martin A. ; Rahbar, Mohammad H. ; Sauer, R. Michelle ; Brasel, Karen J. ; Bulger, Eileen M. ; Myers, John G. ; Phelan, Herb A. ; Alarcon, Louis H. ; Holcomb, John B. / Do-not-resuscitate orders in trauma patients may bias mortality-based effect estimates : An evaluation using the PROMMTT study. In: Journal of Trauma and Acute Care Surgery. 2013 ; Vol. 75, No. 1 SUPPL1.
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abstract = "BACKGROUND: The impact of do-not-resuscitate (DNR) orders has not been systematically evaluated in acute trauma research.We determined the frequency, timing, and impact on mortality-based effect estimates for patients with DNR orders in the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study. METHODS: Trauma patients surviving at least 30 minutes and transfused one or greater unit of red blood cell within 6 hours of admission (n = 1,245) from 10 Level 1 centerswere enrolled.We report descriptive statistics and results from survival analysis to compare the association of blood product transfusion ratios with outcome defined as mortality and as a composite, DNR, and death. RESULTS: DNRs were reported for 95 patients (7.6{\%}), with 94 in-hospital deaths. There were 172 deaths without DNRs. Of 90 known DNR order times, the median was 53 hours (interquartile range, 9Y186 hours) after admission; the median DNR-to-death time was 10 hours (2-32 hours). DNRs were for comfort measures only (43{\%}), no cardiopulmonary resuscitation (40{\%}), and no intubation or cardiopulmonary resuscitation (16{\%}). Compared with the 116 non-DNR deaths that occurred after the earliest DNR order (2 hours), the DNR decedents were significantly older with a less severe base deficit, fewer red blood cell and plasma transfusions, and a later median time of death (98 [21-230] hours vs. 17 [4-91] hours). In multivariable Cox models that accounted for time-varying blood product ratios, the associations were consistent, regardless of whether outcome was defined as mortality or the composite. CONCLUSION: DNR orders were instituted after the 24-hour period of highest mortality risk and more often in older patients not in severe shock. Findings from the primary PROMMTT analyses of the impact of blood product ratios on survival did not materially change when the original mortality outcome was redefined as a composite of DNR or death. DNR orders are potentially an important mediating variable that should be systematically evaluated in trauma research.",
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T1 - Do-not-resuscitate orders in trauma patients may bias mortality-based effect estimates

T2 - An evaluation using the PROMMTT study

AU - Wade, Charles E.

AU - Del Junco, Deborah J.

AU - Fox, Erin E.

AU - Cotton, Bryan A.

AU - Cohen, Mitchell J.

AU - Muskat, Peter

AU - Schreiber, Martin A.

AU - Rahbar, Mohammad H.

AU - Sauer, R. Michelle

AU - Brasel, Karen J.

AU - Bulger, Eileen M.

AU - Myers, John G.

AU - Phelan, Herb A.

AU - Alarcon, Louis H.

AU - Holcomb, John B.

PY - 2013

Y1 - 2013

N2 - BACKGROUND: The impact of do-not-resuscitate (DNR) orders has not been systematically evaluated in acute trauma research.We determined the frequency, timing, and impact on mortality-based effect estimates for patients with DNR orders in the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study. METHODS: Trauma patients surviving at least 30 minutes and transfused one or greater unit of red blood cell within 6 hours of admission (n = 1,245) from 10 Level 1 centerswere enrolled.We report descriptive statistics and results from survival analysis to compare the association of blood product transfusion ratios with outcome defined as mortality and as a composite, DNR, and death. RESULTS: DNRs were reported for 95 patients (7.6%), with 94 in-hospital deaths. There were 172 deaths without DNRs. Of 90 known DNR order times, the median was 53 hours (interquartile range, 9Y186 hours) after admission; the median DNR-to-death time was 10 hours (2-32 hours). DNRs were for comfort measures only (43%), no cardiopulmonary resuscitation (40%), and no intubation or cardiopulmonary resuscitation (16%). Compared with the 116 non-DNR deaths that occurred after the earliest DNR order (2 hours), the DNR decedents were significantly older with a less severe base deficit, fewer red blood cell and plasma transfusions, and a later median time of death (98 [21-230] hours vs. 17 [4-91] hours). In multivariable Cox models that accounted for time-varying blood product ratios, the associations were consistent, regardless of whether outcome was defined as mortality or the composite. CONCLUSION: DNR orders were instituted after the 24-hour period of highest mortality risk and more often in older patients not in severe shock. Findings from the primary PROMMTT analyses of the impact of blood product ratios on survival did not materially change when the original mortality outcome was redefined as a composite of DNR or death. DNR orders are potentially an important mediating variable that should be systematically evaluated in trauma research.

AB - BACKGROUND: The impact of do-not-resuscitate (DNR) orders has not been systematically evaluated in acute trauma research.We determined the frequency, timing, and impact on mortality-based effect estimates for patients with DNR orders in the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study. METHODS: Trauma patients surviving at least 30 minutes and transfused one or greater unit of red blood cell within 6 hours of admission (n = 1,245) from 10 Level 1 centerswere enrolled.We report descriptive statistics and results from survival analysis to compare the association of blood product transfusion ratios with outcome defined as mortality and as a composite, DNR, and death. RESULTS: DNRs were reported for 95 patients (7.6%), with 94 in-hospital deaths. There were 172 deaths without DNRs. Of 90 known DNR order times, the median was 53 hours (interquartile range, 9Y186 hours) after admission; the median DNR-to-death time was 10 hours (2-32 hours). DNRs were for comfort measures only (43%), no cardiopulmonary resuscitation (40%), and no intubation or cardiopulmonary resuscitation (16%). Compared with the 116 non-DNR deaths that occurred after the earliest DNR order (2 hours), the DNR decedents were significantly older with a less severe base deficit, fewer red blood cell and plasma transfusions, and a later median time of death (98 [21-230] hours vs. 17 [4-91] hours). In multivariable Cox models that accounted for time-varying blood product ratios, the associations were consistent, regardless of whether outcome was defined as mortality or the composite. CONCLUSION: DNR orders were instituted after the 24-hour period of highest mortality risk and more often in older patients not in severe shock. Findings from the primary PROMMTT analyses of the impact of blood product ratios on survival did not materially change when the original mortality outcome was redefined as a composite of DNR or death. DNR orders are potentially an important mediating variable that should be systematically evaluated in trauma research.

KW - Resuscitation

KW - Survival

KW - Withdrawal of care

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