Characteristics of patients receiving or foregoing resuscitation at the time of cardiopulmonary arrest.

OBJECTIVE: To compare clinical, functional and social characteristics of DNR patients at the time of their cardiopulmonary arrest with characteristics of patients who receive cardiopulmonary resuscitation. DESIGN: Retrospective chart review of all 261 patients who had a cardiopulmonary arrest during a 6-month period in an academic institution. SETTING: Teaching Veterans Affairs Medical Center serving a large metropolitan area. MEASUREMENTS: Demographic characteristics, medical diagnoses, and measures of functional status were collected when DNR orders were initiated and at the time of cardiopulmonary arrest. RESULTS: The mean age of the studied group was 62 years. Ninety-nine percent were males, and the majority were non-Hispanic white men. One hundred ninety-eight (76%) patients/proxies elected for limiting treatment. Most (85%) elected a DNR order only. Patients were the most frequently documented participants in advance directive decisions in the DNR group. At the time of cardiopulmonary arrest, a higher proportion of the CPR group had coronary artery disease or chronic renal failure, and a higher proportion of the DNR group had cancer or AIDS. The functional status of the DNR group deteriorated from the time of DNR order to death. At the time of cardiopulmonary arrest, the majority of both groups were dependent in all functional domains, and 70% of the DNR group were stuporous or comatose compared with 47% of the CPR group (P = .05). DNR patients were hospitalized for an average of 13.7 +/- 29.5 days after a DNR order was initiated. Six of the 81 patients who received CPR (7.4%) were alive at discharge. CONCLUSIONS: Patients and physicians deciding to implement a DNR order may be overly focused on medical diagnoses and less so on functional status. A significant proportion of patients with clinical characteristics associated with poor CPR outcome are electing for CPR.

Continuity of do-not resuscitate orders between hospital and nursing home settings.

OBJECTIVE: To determine the relationship between interinstitutional communication and continuity of advance directives from hospital to nursing home (NH) settings. DESIGN: Retrospective chart review of discharges to hospital affiliated or community NHs. SETTING: Teaching Veterans Affairs Hospital and affiliated and community nursing homes. MEASUREMENTS: Demographic characteristics, medical diagnoses, presence of advance directives, and documentation that relates to the topic. RESULTS: A total of 83 patients were discharged to either setting. Before discharge to a NH, the prevalence of chronic obstructive pulmonary disease and cancer was higher among those who had a DNR order. Overall, subsequent discussions about advance directives were equally common in NHs. Having a hospital discussion about advance directives or having a hospital DNR order were associated with a higher rate of advance directive discussions in NHs. Hospital DNR orders were continued for 93% and 41% of patients admitted to the hospital-affiliated NH compared with community NHs, respectively (P < .001). Specific communication of hospital DNR status to the receiving NH was associated with better continuity of DNR orders (49% vs 9%, P = .001). Factors that predicted continuity of DNR orders in logistic regression analysis correctly included hospital DNR status, communication of advance directives to the receiving NH, and NH advance directive discussions. CONCLUSIONS: There is higher continuation rate of DNR orders between the hospital under study and its affiliated NH than to community NHs despite a similar frequency of confirmation discussions. Completing advance directives before patients are discharged to NHs, communication of advance directives to the receiving NH, and follow-up discussions at the NH may improve the continuity of advance directives between hospitals and nursing homes.

Limiting treatment in nursing homes: knowledge and attitudes of nursing home medical directors.

OBJECTIVE: To determine nursing home medical directors' knowledge about cardiopulmonary resuscitation outcome and their support of treatment limitation requests and policies. DESIGN: Mailed questionnaire, followed by telephone interview. PARTICIPANTS: Forty-six medical directors of 70 community nursing homes in Harris County, Texas. MEASUREMENTS: Medical directors were asked to estimate the CPR survival rate to discharge of all nursing home residents and that of two case scenarios. They were asked to indicate on a Likert scale their support for mandatory Do-Not-Resuscitate orders and for requests by nursing home patients to withhold other life support measures. RESULTS: Responses were received from 33 directors. Overall CPR survival rate of older nursing home residents after cardiac arrest was thought to be 10.7%. The average CPR survival rate for healthy older people with witnessed arrests was believed to be 13.8%. The perceived rate for unwitnessed arrests in terminal patients was 4.6%, significantly lower than estimates for healthy older people (P = .003) and estimates of the overall survival rate (P = .02). Medical directors were split regarding mandatory Do-Not-Resuscitate orders for patients in vegetative states, with terminal illness, with an unwitnessed arrest, or in those older than 90 years of age. Mandatory use of Do-Not-Resuscitate orders for all nursing home residents was strongly opposed. Assuming a 2% survival rate did not significantly influence medical directors' opinions about mandatory DNR orders in these groups. Medical directors were more willing to support requests by stable nursing home residents to withhold resuscitation, mechanical ventilation, or hospitalization than requests to withhold antibiotics, intravenous fluids, or tube feedings (P < .005). The majority of medical directors were willing to withhold all such measures for terminal patients. CONCLUSIONS: Health care professionals who are responsible for educating patients about the efficacy of cardiopulmonary resuscitation in nursing homes overestimate its benefit and may benefit from further education about its outcome. Although mandatory Do-Not-Resuscitate orders were favored for terminal or vegetative patients, medical directors are not supportive of such orders across the board. Medical directors are more willing to honor requests for treatment limitation by terminal patients than others.

Older nursing home residents have a cardiac arrest survival rate similar to that of older persons living in the community.

OBJECTIVE: To determine the survival rates of older nursing home residents after cardiopulmonary resuscitation (CPR) and to compare it with that of older persons who experienced cardiac arrest in an outpatient setting. To identify patient characteristics, arrest characteristics, and effort characteristics that are associated with higher survival rates. DESIGN: Retrospective review of emergency medical service charts and hospital medical records of a cohort of older nursing home residents (n = 114) after cardiopulmonary resuscitation and a matched cohort of community-residing older persons (n = 228) matched on age, gender, and year of cardiac arrest. SETTING: A large metropolitan city served by a tiered emergency medical service. MEASUREMENTS: Independent variables related to patient, cardiac arrest, and resuscitation effort characteristics. Dependent variables were defined as immediate survival after cardiopulmonary resuscitation and survival status at discharge. RESULTS: The mean age of nursing home residents was 80.3 years; 62.3% were females. The majority of cardiac arrests for both groups were unwitnessed (67%) and had agonal rhythms (asystole and electromechanical dissociation). Emergency medical service efforts were similar for the two cohorts. Among nursing home residents, 26.3% had a return of blood pressure for more than 5 minutes, 70.2% were pronounced dead in the emergency room, and 10.5% were discharged from hospitals alive. In the matched community-residing subjects, 22.7% had a return of blood pressure, 78.1% were pronounced dead in the emergency room, and 9.2% were discharged alive. Between-group comparisons of these variables revealed no significant differences even though our sample size was adequate. CONCLUSIONS: We conclude that survival after cardiac arrest of older persons residing in nursing homes is low; however, with an appropriate CPR/DNR selection process and an effective emergency medical system, survival of certain groups of nursing home residents following cardiac arrest could be comparable to that of community residing older persons. Despite the reasonably good survival rates for older persons seen above, our analyses indicated that patients who have unwitnessed arrests are not likely to survive to discharge and that patients with initial rhythms such as asystole or electromechanical dissociation rarely survive. These data suggest that patients who have an unwitnessed arrest in the nursing home should not receive resuscitation attempts, and in those patients for whom paramedics are called, resuscitation efforts should not proceed any further if their original rhythm is asystole or electromechanical dissociation. Thus, modification in nursing home policies regarding CPR efforts is needed.

Estimation of severity of illness with APACHE II: age-related implications in cardiac arrest outcomes.

The ability to predict outcomes of cardiac arrest before starting cardiopulmonary resuscitation (CPR) would be useful for discussions of resuscitation with elders and their families. We thought CPR outcome might be dependent on the severity of pre-existing illnesses. The APACHE II is a severity-of-illness (SOI) scale based, in part, on physiologic parameters whereby points are given for degree of deviation from normal. Additionally, up to six points are given for increased age. We hypothesized that (1) patients with the highest APACHE II would be least likely to survive, and (2) because of the blunted physiologic responsiveness, the APACHE II would underestimate the SOI of elderly patients who were sufficiently ill to have a cardiac arrest. A retrospective study of 172 arrests was carried out to evaluate these hypotheses. For the young cohort (n = 126; age, < 70; mean age, 59 +/- 8), mean admission APACHE II was 16.5 +/- 7.9 and pre-arrest APACHE II regression analysis.2+ carried out with both APACHE II scores and factors previously correlated with CPR outcome. Witnessed arrests and those requiring a low number of medications were most likely to result in immediate success (restoration of blood pressure) and in a live discharge. APACHE II score (24 h pre-arrest) was associated with live discharge in the regression analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

4-MAPC, a 5 alpha-reductase inhibitor, reduces rat ventral prostate weight, DNA, and prostatein concentrations.

Several compounds, such as 4-MAPC (4-methyl-3-oxo-4-aza-5 alpha-pregnane-20- carboxylate), that inhibit conversion of testosterone (T) to dihydrotestosterone (DHT) by 5 alpha-reductase have been demonstrated to reduce prostate size in rats and dogs. The current studies were undertaken to determine if this effect is due to a reduction in cell number, in epithelial cell synthetic activity, or both. Eight-week-old intact rats were treated daily for 14 days with sesame seed oil, 4-MAPC (10 mg/kg), 4-MAPC + testosterone propionate (TP, 1 mg/kg), or 4-MAPC + TP (3 mg/kg). Rats were killed 24 hours after the last injection. In the animals treated only with 4-MAPC, ventral prostate weight was reduced 37%, but the 14% reduction in total DNA was not significant. The mean intraprostatic concentration of prostatein, a major secretory protein, was reduced 45% (P less than 0.05). The 3 mg/kg dose of TP increased ventral prostate weight, prostatein concentrations, and acid phosphatase activity, even though DNA/ventral prostate was similar to that in control animals. These observations indicate that the reduction in ventral prostate weight in adult rats is due in part to a reduction in cell number, but the primary effect was due to a reduction in synthetic activity, and possibly atrophy of the epithelial cells. Furthermore, TP in pharmacologic doses increased ventral prostate weight and synthetic activity without increasing DNA.