Factors influencing DNR decision-making in a surgical ICU

BACKGROUND: End-of-life decisions in the surgical ICU can be complicated by the unique characteristics of perioperative illness and the focus on life-extending interventions. We sought to determine whether illness severity correlated with the presence of DNR order in critically ill surgical patients. STUDY DESIGN: All surgical ICU patients who were given a DNR order from May 1, 1991 to May 31, 1998 were identified. Demographic data for all patients were collected prospectively. Patients who died without a DNR order were compared with patients with DNR orders. Variables in the analysis included date of DNR order, age, ICU, and hospital lengths of stay, APACHE II and III scores and maximum multiple organ dysfunction scores, past medical history, and mortality. ANOVA, multivariate ANOVA, and chi-square statistical tests were used to analyze the data, with p :5 0.05 used to reject the mill hypothesis. RESULTS: Mortality for DNR patients was 84.7%. Multiple organ dysfunction syndrome was ubiquitous in this group of patients. There were no differences between DNR and no-DNR groups on the basis of age or APACHE III score or multiple organ dysfunction score. ICU lengths of stay were substantially higher in the patients made DNR, 1.8 +/- 0.1 versus 1.0 +/- 0.1, p = 0.0001, and 16.9 +/- 0.2 versus 12.1 +/- 1.2, p = 0.011, respectively. Multivariate ANOVA revealed that only past medical history predicted a DNR order. CONCLUSIONS: Although acuity of illness and organ dysfunction consistently predicted mortality in critically ill patient populations, only elements of the past medical history were positively associated with a DNR order in critically ill surgical patients. Additional prospective studies need to be performed to determine the relative influences of physiologic, demographic, and sociologic factors on the creation of DNR orders in critically ill surgical patients.