Impact of survival probability, life expectancy, quality of life and patient preferences on do-not-attempt-resuscitation orders in a hospital

Consensus exists that a do-not-attempt-resuscitation order (DNAR) is approp riate if a resuscitation attempt is futile. Less agreement exists when this point is reached. We investigated the influence of three major considerati ons for in-hospital DNAR orders: expected survival probability after resusc itation, prospects of the patients? current condition without a cardiac arr est and the patients' autonomous decision not to want resuscitation. We cal culated an expected survival probability according to two multi-morbidity p rediction scores for each patient, assuming the event of cardiac arrest. Th e prospects of the current condition without a cardiac arrest was estimated by the patients' physician, in terms of life expectancy and quality of lif e (level of dependency after discharge and pain). The patients' preference was documented from the medical records. A total of 470 patients were inclu ded in the study. Fifty-eight patients (12%) had a DNAR-order, 11 of these patients (19%) wanted no resuscitation. The patients' prospects (life expec tancy, dependency after discharge), and age proved to be independently asso ciated with the presence of a DNAR order. The odds ratio (OR) for the prese nce of a DNAR order was 37 (CL 14-107) for an estimated life expectancy les s than 3 months, 13 (CL 4-41) for a life in a nursing home and four (CL 2-1 2) for an age of 80 years and older. Expected survival probability after re suscitation and pain were not independently associated with a DNAR order. W e conclude that resuscitation is considered futile on the basis of the pati ents' age and prospects without cardiac arrest and that the impact of expec ted survival probability on these decisions is small. (C) 1998 Elsevier Sci ence Ireland Ltd. All rights reserved.