Current practice of Do-Not-Resuscitate (DNR) orders in a Saudi Arabian tertiary care center

Background

DNR is a new concept in Saudi Arabia. King Fahad National Guard Hospital has been a national leader in raising the awareness about the futility of aggressive life support in terminally ill patients. The purpose of the study is to identify the factors associated with DNR status in our institution.

Methods

We reviewed records of all adult patients who died in 1998. We evaluated patients' demographics, underlying chronic illnesses, admission diagnosis, length of stay, the timing of writing DNR orders and whether death occurred in the ward or in the ICU. Univariate analysis was performed to identify predictors of DNR status. Results are displayed as odds ratios (OR) and 95% confidence intervals.

Results

DNR orders were written for 318/420 deaths (76%). One third (34%) of all deaths occurred in ICU. DNR orders were written for 66% of ICU deaths and 82% of ward deaths. There were no differences in age, gender and length of stay between DNR and fully supported patients. Patients with cancer and cirrhosis were more likely to get DNR orders (OR 2.7 [CI 1.4–4.9], OR 2.6 [CI 1.3–5.1], respectively), while patients with chronic cardiac disease were less likely to be made DNR (OR 0.4 [CI 0.3–0.8]). DNR orders were less likely to be written for patients admitted with acute cardiac disease or trauma (OR 0.3 [CI 0.2–0.5], OR 0.3 [CI 0.1–0.8], respectively) and more likely for patients with sepsis (OR 1.3 [CI 1.2–2.9]). DNR orders were more likely to be written on day 1 of hospitalization in cancer patients (OR 2.5 [1.4–4.5]) and on the last hospital day in cirrhotic and GI bleed patients (OR 2.8 [CI 1.6–5.1], OR 3.7 [CI 1.6–8.4], respectively).

Conclusions

1. The majority of the patients dying in our hospital have DNR orders by the time of death. 2. Dying patients with cancer, cirrhosis and those admitted with sepsis are less likely to be resuscitated, whereas dying cardiac and trauma patients are more likely to continue receiving full support. 3. DNR status tends to be initiated early in cancer patients reflecting the awareness of limited value of aggressive life support in this group of patients. 4. The delay in DNR orders in cirrhotic patients in our institution reflects the fact that the majority of cirrhosis patients were referred for possible liver transplantation.