Sociodemographic factors and the assignment of do-not-resuscitate orders in patients with acute myocardial infarctions

OBJECTIVES. This study examined the impact of sociodemographic and clinical factors, measured at the individual or ecological (zip code) level, on the assignment of do-not-resuscitate (DNR) orders. DESIGN. This was a retrospective study (analysis of secondary data). SUBJECTS. We used a probability sample of 974 patients admitted to 30 mediu m to large California hospitals with acute myocardial infarctions in 1990 t o 1991; the sample was originally designed to validate risk adjustment with administrative data. METHODS. Multivariate logistic regression was used to adjust DNR assignment for age, gender, race, probability of death, functional impairments, payme nt source, hospital teaching status, and ecological measures of educational attainment, home ownership, and income. RESULTS, DNR assignment was inversely associated with black race and positi vely associated with age, probability of death, cognitive impairment, and p oor nutritional status. When the probability of death was very low, DNR ord ers were assigned less frequently to men than to women (odds ratio [OR], 0. 4; 95% confidence interval [CI], 0.2 to 0.7 at probability of death = 0.10) , However, men were significantly more likely to receive a DNR order than w omen when the probability of death was very high (OR, 4.4; 95% CI, 22 to 16 .3 at probability of death = 0.90). CONCLUSIONS. Older, white, sicker, or functionally impaired patients receiv e DNR orders more often than younger, black, healthier, or functionally int act patients do. Adjusting for these factors, DNR assignment is associated with gender through an interaction involving the probability of death. Futu re studies should reexamine the impact of these factors on DNR assignment a nd explore the role of patient values and patient-physician communication b arriers.