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 Schreiber, Mohammad H. Rahbar, R. Michelle Sauer, Karen 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; Rahbar, Mohammad H.; Sauer, R. Michelle; Brasel, Karen; 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, M, Rahbar, MH, Sauer, RM, Brasel, K, 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 ; Rahbar, Mohammad H. ; Sauer, R. Michelle ; Brasel, Karen ; 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.
    @article{2452e39ffc6f4794a4bc9eba4a0ef551,
    title = "Do-not-resuscitate orders in trauma patients may bias mortality-based effect estimates: An evaluation using the PROMMTT study",
    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.",
    keywords = "Resuscitation, Survival, Withdrawal of care",
    author = "Wade, {Charles E.} and {Del Junco}, {Deborah J.} and Fox, {Erin E.} and Cotton, {Bryan A.} and Cohen, {Mitchell J.} and Peter Muskat and Martin Schreiber and Rahbar, {Mohammad H.} and Sauer, {R. Michelle} and Karen Brasel and Bulger, {Eileen M.} and Myers, {John G.} and Phelan, {Herb A.} and Alarcon, {Louis H.} and Holcomb, {John B.}",
    year = "2013",
    doi = "10.1097/TA.0b013e31828fa422",
    language = "English (US)",
    volume = "75",
    journal = "Journal of Trauma and Acute Care Surgery",
    issn = "2163-0755",
    publisher = "Lippincott Williams and Wilkins",
    number = "1 SUPPL1",

    }

    TY - JOUR

    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

    AU - Rahbar, Mohammad H.

    AU - Sauer, R. Michelle

    AU - Brasel, Karen

    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

    UR - http://www.scopus.com/inward/record.url?scp=84880410063&partnerID=8YFLogxK

    UR - http://www.scopus.com/inward/citedby.url?scp=84880410063&partnerID=8YFLogxK

    U2 - 10.1097/TA.0b013e31828fa422

    DO - 10.1097/TA.0b013e31828fa422

    M3 - Article

    C2 - 23778517

    AN - SCOPUS:84880410063

    VL - 75

    JO - Journal of Trauma and Acute Care Surgery

    JF - Journal of Trauma and Acute Care Surgery

    SN - 2163-0755

    IS - 1 SUPPL1

    ER -