DNR orders in SARS-CoV-2 patients: a retrospective validation study in a Swiss COVID-19 Center

  1. Giorgia Lo Presti
  2. Maira Biggiogero
  3. Andrea Glotta
  4. Carola Biondi
  5. Zsofia Horvath
  6. Rosambra Leo
  7. Giovanni Bona
  8. Alessandra Franzetti-Pellanda
  9. Andrea Saporito
  10. Samuele Ceruti
  11. Xavier Capdevila

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Abstract

Background

The worldwide pandemic situation forced many hospitals to adapt COVID-19 management strategies. In this scenario, the Swiss Academy of Medical Sciences (SAMW/ASSM) organized national guidelines based on expert opinion to identify Do-Not-Resuscitate (DNR) patients, to reduce futile ICU admission and resource misuse. However, the practical impact of this standardized national protocol has not been yet evaluated. In our specialized COVID-19 Center, we investigated characteristics and mortality of DNR patients identified according to national standardized protocol, comparing them to non-DNR patients.

Methods

This was a pilot retrospective validation study, evaluating consecutive hospital admitted COVID-19 patients. Primary outcome was 30-days survival of DNR patients in comparison to the control group . Secondary outcomes reported quality of treatment of deceased patients, especially of agitation/sedation and dyspnea, using respectively the Richmond Agitation-Sedation Scale – Palliative care (RASS-PAL) for sedation and agitation (+4/-5) and the modified Borg Scale for dyspnea (1-10).

Results

From March 16 to April 1, 2020, 213 consecutive patients were triaged; at 30-days follow-up, 9 patients (22.5%) died in the DNR group , 4 (2.2%) in the control group . The higher mortality rate in the DNR group was further confirmed by Log-Rank Mantel-Cox (23.104, p < 0.0001). In the DNR-group deceased patients, end-of-life support was performed with oxygen (100%), opioids (100%) and sedatives (89%); the mean RASS-PAL improved from 2.2 to -1.8 (p < 0.0001) and the Borg scale improved from 5.7 to 4.7 (p = 0.581).

Conclusion

A national standardized protocol identified patients at higher risk of short-term death. Although the legal status of DNRs varies from country to country, the implementation of national standardized protocol could be the way to guarantee a better treatment of COVID-19 patients in a pandemic situation with limited resources.

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  1. Version published to 10.1101/2021.07.12.21260359v2 on medRxiv
  2. ScreenIT

    SciScore for 10.1101/2021.07.12.21260359: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    EthicsIRB: Ethics considerations: The project has been approved by the local Ethics Committees according to the local Federal rules.
    Consent: All the participants provided a written informed consent form.
    Sex as a biological variablenot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Statistical data analysis was performed using the SPSS 25.0 package (SPSS Inc, USA).
    SPSS
    suggested: (SPSS, RRID:SCR_002865)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Our study presented some limitations. Firstly, it was a retrospective collection of cohort patients, with small sample of DNR patients. However, the significance of statistical tests remains high and should induce other groups to carry out future prospective validations in this direction. Secondly, the group of DNR patients presented a median age greater than the control group; this may reflect the presence of co-morbidities, a key-elements necessary to identify DNR patients according to SAMW/ASSM guidelines. The increased mortality rate in DNR group was at a short-term of 30 days, so that the only presence of a median age of 80 years was not sufficient to explain this increase in mortality. Thirdly, in our scenario, due to resource re-allocations, DNR patients have not been treated by certified Palliative Physicians; this may have negatively influenced the obtained results on secondary outcomes. Fourth, in our analysis of palliative care we decided to evaluate only the administration of opiates and sedatives, and their effects due to the retrospective design of the study, as a more specific information in this context resulted incomplete. Finally, we did not investigate the follow-up in terms of hospital discharge, transfer to other facilities or survival after 30 days, mainly because the primary outcome of our study was to investigate the 30-day overall survival in COVID-19 patients, comparing DNR to not DNR. In conclusion, the high mortality rate in COVID-19 patients enhan...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    Results from scite Reference Check: We found no unreliable references.

    About SciScore

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  3. Version published to 10.1101/2021.07.12.21260359v1 on medRxiv