UNASSIGNED: Patients from diverse sociocultural backgrounds and with differing medical conditions may have varying levels of acceptance of advanced care planning and palliative care.
UNASSIGNED: We performed a retrospective analysis of the National Inpatient Sample for patients discharged from January 1, 2016, to December 31, 2019, with conditions associated with frequently terminal conditions. We recorded demographic variables, do not resuscitate (DNR) status, and palliative care (PC) status and analyzed the associations between outcomes, mortality, and length of stay (LOS).
UNASSIGNED: A total of 23,402,637 patient records were included in the study, of which 2% were DNR and PC, 5% were DNR only, and 1% was PC only. From 2016 to 2019, the percentage of patients with PC increased from 2.55% to 3.27% and DNR from 6.31% to 7.7%. Black patients were less likely to have DNR status (odds ratio [OR] 0.72 [0.71-0.72]) but had similar PC rates. Male patients were less likely to have a DNR order in place (OR 0.89 [0.89-0.89]) but more likely to be in PC (OR 1.05 [1.04-1.05]). The diagnoses with the highest association with DNR status were lung cancer (OR 4.1 [4.0-4.5]), pancreatic cancer (OR 4.6 [4.5-4.7]), and sepsis (OR 2.9 [2.9-2.9]) The diagnoses most associated with PC were lung cancer (OR 6.3 [6.2-6.4]), pancreatic cancer (OR 8.1 [7.1-8.3]), colon cancer (OR 4.9 [4.8-5.1]), and senile brain degeneration of the brain OR 6.5 [5.3-7.9]). Mortality and LOS decreased between 2016 and 2019, but hospital charges increased (p < 0.001). Black race and male gender were associated with higher inpatient mortality (OR 1.12 [1.12-1.14]), LOS, and hospital charges.
UNASSIGNED: In the United States, the proportion of hospitalized patients with DNR, PC, and DNR with PC increased from 2016 to 2019. Overall, inpatient mortality and LOS fell, but hospital charges per patient increased. Significant gender and ethnic differences emerged. Black patients and males were less likely to have DNR status and had higher inpatient mortality, LOS, and hospital charges.

OBJECTIVE: In-hospital cardiac arrest (IHCA) is a major cause of mortality globally, and over 50% of the survivors will require institutional care as a result of poor neurological outcome. It is important that physicians discuss the likely outcome of resuscitation with patients and families during end-of-life discussions to help them with decisions about cardiopulmonary resuscitation. We aim to compare three consultants\' do-not-resuscitate (DNR) decisions with the GO-FAR score predictions of the probability of survival with good neurological outcomes following in-hospital cardiac arrest (IHCA).
METHODS: This is a retrospective study of all patients 18 years or older placed on a DNR order by a consensus of three consultants in a tertiary institution in the United Arab Emirates over 12 months. Patients\' socio-demographics and the GO-FAR variables were abstracted from the electronic medical records. We applied the GO-FAR score and the probability of survival with good neurological outcomes for each patient.
RESULTS: A total of 788 patients received a DNR order, with a median age of 71 years and a majority being males and expatriates. The GO-FAR model categorized 441 (56%) of the patients as having a low or very low probability of survival and 347 (44%) as average or above. There were 219 patients with a primary diagnosis of cancer, of whom 148 (67.6%) were in the average and above-average probability groups. There were more In-hospital deaths among patients in the average and above-average probability of survival group compared with those with very low and low probability (243 (70%) versus 249 (56.5%) (P < 0.0001)). The DNR patients with an average or above average chance of survival by GO-FAR score were more likely to be expatriates, oncology patients, and did not have sepsis.
CONCLUSIONS: The GO-FAR score provides a guide for joint decision-making on the possible outcomes of CPR in the event of IHCA. The physicians\' recommendation and the ultimate patient\'s resuscitation choice may differ due to more complex contextual medico-social factors.

OBJECTIVE: In case of out-of-hospital cardiac arrest (OHCA) personnel of the emergency medical services (EMS) are regularly confronted with advanced directives (AD) and do-not-attempt-resuscitation (DNACPR) orders. The authors conducted a retrospective analysis of EMS operation protocols to examine the prevalence of DNACPR in case of OHCA and the influence of a presented DNACPR on CPR-duration, performed Advanced-Life-Support (ALS) measures and decision making.
METHODS: Retrospective analysis of prehospital medical documentation of all resuscitation incidents in a German county with 250,000 inhabitants from 1 January 2016 to 31 December 2022. Combined with data from the structured CPR team-feedback database patients characteristics, measures and course of the CPR were analysed. Statistic testing with significance level p < 0.05.
RESULTS: In total n = 1,474 CPR events were analysed. Patients with DNACPR vs. no DNACPR: n = 263 (17.8%) vs. n = 1,211 (82.2%). Age: 80.0 ± 10.3 years vs. 68.0 ± 13.9 years; p < 0.001. Patients with ASA-status III/IV: n = 214 (81.3%) vs. n = 616 (50.9%); p < 0.001. Initial layperson-CPR: n = 148 (56.3%) vs. n = 647 (55.7%); p = 0.40. Airway management: n = 185 (70.3%) vs. n = 1,069 (88.3%); p < 0.001. With DNACPR CPR-duration initiated layperson-CPR vs. no layperson-CPR: 19:14 min (10:43-25:55 min) vs. 12:40 min (06:35-20:03 min); p < 0.001.
CONCLUSIONS: In case of CPR EMS-personnel are often confronted with DNACPR-orders. Patients are older and have more previous diseases than patients without DNACPR. Initiated layperson-CPR might lead to misinterpretation of patients will with impact on CPR-duration and unwanted measures. Awareness of this issue should be created through measures such as training programs in particular to train staff in the interpretation and legal admissibility of ADs.

We aim to study the characteristics and outcomes of patients with a Do-Not-Attempt Resuscitation and to determine its impact on the Cost of In-Hospital Cardiac Arrest. A retrospective study of all adult patients admitted to the hospital from June 2021 to May 2022 who had a Do-Not-Resuscitate order. We abstracted patients\' socio-demographics, physiologic parameters, primary diagnosis, and comorbidities from the electronic medical records. We calculated the potential economic cost using the median ICU length of stay for the admitted IHCA patients during the study period. There were 28,866 acute admissions over the study period, and 788 patients had DNR orders. The median (IQR) age was 71 (55-82) years, and 50.3% were males. The most prevalent primary diagnosis was sepsis, 426 (54.3%), and cancer was the most common comorbidity. More than one comorbidities were present in 642 (80%) of the cohort. Of the DNR patients, 492 (62.4%) died, while 296 (37.6%) survived to discharge. Cancer was the primary diagnosis in 65 (22.2%) of those who survived, compared with 154 (31.3%) of those who died (P = 0.002). Over the study period, 153 patients had IHCA and underwent CPR, with an IHCA rate of 5.3 per 1,000 hospital admissions. Without a DNR policy, an additional 492 patients with cardiac arrest would have had CPR, resulting in an IHCA rate of 22.3 per 1000 hospital admissions. Most DNR patients in our setting had sepsis complicated by multiple comorbidities. The DNR policy reduced our IHCA incidence by 76% and prevented unnecessary post-resuscitation ICU care.

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OBJECTIVE: To investigate the prevalence of Do not Resuscitate (DNR) code registration in patients with a geriatric profile admitted to Antwerp University Hospital, a tertiary care hospital in Flanders, Belgium, and the impact of comprehensive geriatric assessment (CGA) on DNR code registration.
METHODS: Retrospective analysis of a population of 543 geriatric patients (mean age 82.4 ± 5.19 years, 46.4% males) admitted to Antwerp University Hospital from 2018 to 2020 who underwent a CGA during admission. An association between DNR code registration status before and at hospital admission and age, gender, ethnicity, type of residence, clinical frailty score (CFS), cognitive and oncological status, hospital ward and stay on intensive care was studied. Admissions before and during the first wave of the pandemic were compared.
RESULTS: At the time of hospital admission, a DNR code had been registered for 66.3% (360/543) of patients. Patients with a DNR code at hospital admission were older (82.7 ± 5.5 vs. 81.7 ± 4.6 years, p = 0.031), more frail (CFS 5.11 ± 1.63 vs. 4.70 ± 1.61, p = 0.006) and less likely to be admitted to intensive care. During the hospital stay, the proportion of patients with a DNR code increased to 77% before and to 85.3% after CGA (p < 0.0001). Patients were consulted about and agreed with the registered DNR code in 55.8% and 52.1% of cases, respectively. The proportion of patients with DNR codes at the time of admission or registered after CGA did not differ significantly before and after the start of the COVID-19 pandemic.
CONCLUSIONS: After CGA, a significant increase in DNR registration was observed in hospitalized patients with a geriatric profile.

Background The directive to withhold emergent interventions in the case of cardiac and/or respiratory arrest with the continuation of standard care and therapy is known as do-not-resuscitate (DNR). The diversity of DNR guidelines depends on moral and religious factors. In Saudi Arabia, a DNR policy was published in 2017 which corresponds to the religious and ethical aspects of Islamic law. To augment future awareness regarding DNR decisions, as they are an essential element in critical care medicine, the foundational principles of DNR must be provided during the clinical years of medical school. Objectives The current study aims to assess and evaluate the knowledge and attitudes regarding DNR decisions among clinical-year medical students and interns in the Western Region of Saudi Arabia. Methods A cross-sectional study was carried out from October to December 2023, utilizing a self-administered online survey distributed via social media platforms. After receiving ethical approval from the institutional review board, data were collected from clinical-year medical students and interns in the Western Region of Saudi Arabia, and an appropriate statistical analysis was performed. Results A total of 397 participants were enrolled in this study. More than half (n = 251, 63.2%) were from Umm Al-Qura University, while the remaining (n=79, 19.9%) were from Taibah University. Of the total, 258 (65%) were male participants, and 139 (35%) were female. A total of 152 (38.3%) were fifth-year medical students, and 102 (25.7%) were interns. The vast majority (n = 364, 91.7%) had heard the term DNR, with the most reported source of information being from healthcare providers (n = 306, 83.2%), while a minority (n = 33, 8.3%) had not. Of the respondents, 226 (56.9%) identified the presence of a clear DNR policy in Saudi Arabia, and 77 (19.4%) had previously had experience with DNR. Most of the studied population (n = 333, 83.9%) expressed a willingness to take a lecture/session regarding DNR. Most of our participants, 347 (87.4%), believe it is essential to consider legal concerns when making a DNR decision. Interestingly, 152 (38.5%) of the participants think it is acceptable to be conservative in investigations and treatments with patients who are labeled as DNR, and 223 (56.2%) agree that patients should be aware of their DNR status. Approximately three-quarters of the study population (n = 290, 73%) agreed that it is stressful to discuss the possibility of a DNR order. In the association of who heard about DNR more, 101 (99%) of the interns had heard about the term DNR, while only 53 (75.7%) of the fourth-year medical students had. At the same time, 74 (72.5%) of the interns showed a positive attitude regarding the DNR definition, compared to 33 (47.1%) of the fourth-year medical students. Conclusion This study highlights the necessity of integrating educational interventions into DNR decisions in addition to clinical placement in the intensive care unit as part of the medical school curriculum.

OBJECTIVE: To identify the preferences of small animal veterinary clients for the timing of communication during CPR and whether these clients prefer the veterinarian or pet owner to decide on the termination of resuscitation.
METHODS: Surveys (n = 1,648) were completed between January 20 and February 3, 2023, by clients of the Wilford and Kate Bailey Small Animal Teaching Hospital.
METHODS: This cross-sectional observational study used an anonymous internet-based survey distributed to 28,000 clients of an academic small animal veterinary hospital. The survey included 16 questions asking for the respondents\' demographics, healthcare professional status, questions pertaining to CPR, and preference for timing of communication during CPR, veterinary team members to speak to, and the decision on termination of resuscitation. An optional open comment section was provided.
RESULTS: The response rate was 7.5%, including 2,127 responses, with 1,648 complete responses used for further analysis. Of the respondents, 56% and 63% (when asked using a short and long scenario question, respectively) would prefer to be informed about their pet undergoing CPR after CPR has ended. Most clients (84%) wanted the veterinarian to decide when to stop CPR. In the comments section, clients predominantly emphasized that patient care should always be prioritized over client communication.
CONCLUSIONS: This study contributes to a better understanding of veterinary clients\' preferences and may help improve client communication and decision-making during CPR. More studies are warranted to reach a wider population before broad recommendations can be made.

OBJECTIVE: The primary objective was to evaluate if the percentage of patients with missing or inaccurate code status documentation at a Trauma Level 1 hospital could be reduced through daily updates. The secondary objective was to examine if patient preferences for DNR changed during the COVID-19 pandemic.
METHODS: This retrospective study, spanning March 2019 to December 2022, compared the code status in ICU and ED patients drawn from two data sets. The first was based on historical electronic medical records (EHR), and the second involved daily updates of code status following patient admission.
RESULTS: Implementing daily updates upon admission was more effective in ICUs than in the ED in reducing missing code status documentation. Around 20% of patients without a specific code status chose DNR under the new system. During COVID-19, a decrease in ICU patients choosing DNR and an increase in full code (FC) choices were observed.
CONCLUSIONS: This study highlights the importance of regular updates and discussions regarding code status to enhance patient care and resource allocation in ICU and ED settings. The COVID-19 pandemic\'s influence on shifting patient preferences towards full code status underscores the need for adaptable documentation practices. Emphasizing patient education about DNR implications and benefits is key to supporting informed decisions that reflect individual health contexts and values. This approach will help balance the considerations for DNR and full code choices, especially during health care crises.

OBJECTIVE: The purpose of this inquiry is to explore how adult patients with limiting directives, their families, and clinicians make decisions about resuscitative status during anesthesia. Although current practice guidelines recommend mandatory reconsideration of do not resuscitate and other limiting directives before anesthesia, the automatic suspension of directives limiting care continues in the adult perianesthesia setting. How patients and clinicians talk about these limiting directives is underexplored in the literature.
METHODS: This qualitative inquiry used the Foucauldian Poststructural Case Study Design.
METHODS: Data were collected through interviews and observation of patients with existing advance directives who underwent surgery, family members, and perianesthesia clinicians who participated in their care. Contextualizing analysis, a qualitative methodology that fits well with Foucauldian Poststructural Case Study Design, was used to rigorously examine the data.
RESULTS: Twenty-seven participants completed the observation and interview components of the study. Observation data were collected from an additional 18 participants. Four authoritative discourses that constructed choices available to patients and clinicians were identified. The \"We\'ll just suspend\" discourse permeates perianesthesia culture and produces a will to suspend the limiting directive among clinicians. Discourses about lack of time, a desire not to talk about advance directives unless it is essential to care, and confusion about who is responsible for addressing the limiting directive were also identified in the case. In addition, patients had difficulty translating advance directive choices into the perianesthesia context, and this difficulty may be misunderstood by clinicians as agreement with the plan of care. Finally, power networks may sequester knowledge about patients\' choices, leading to tension among clinicians and creating barriers to honoring patients\' advance directive choices.
CONCLUSIONS: Results suggest that even where policies of mandatory advance directive reconsideration exist, patients may experience environments that constrain their choices and decision-making agency.