A patient’s do-not-resuscitate (DNR) status significantly impacts their risk of death from COVID-19, according to a study of an often-overlooked chapter of the nation’s experience with the coronavirus pandemic.
The study, which appeared in Clinics in Dermatology on November 28, is a retrospective, observational cohort analysis of coronavirus patients admitted to two New Jersey hospitals from March 15 to May 15, 2020, who had or developed COVID-19. The study was conducted by a team of physicians and public-health experts.
All told, 1,270 patients were studied. Of the 640 patients who died, 89.1 percent had a DNR order at the time of admission and 10.9 percent did not. Of the 630 patients who survived, 28.6 percent had a DNR order while 71.4 percent did not.
“COVID-19 DNR patients had a significantly higher mortality rate compared to COVID-19 non-DNR patients,” the study found.
A DNR may influence treatment decisions.
“Patients with severe COVID-19 whose physicians feel they need such measures short term to treat the disease may be discouraged from offering them if the patient has a DNR order,” the study adds. “This may unnecessarily negatively impact patient care and increase mortality in COVID-19 patients.”
Driving Up the Statistics of the Pandemic
A DNR is a written instruction signed by an individual telling physicians and health care providers not to perform cardiopulmonary resuscitation (CPR), a life-saving emergency technique that restores heart and lung function.
“DNR status is often linked to patients with severe illness, advanced age, poor disease prognosis, and deteriorating health status with impending death,” the authors state. “Data are lacking on survivability of inpatient cardiac arrest for COVID-19 patients.”
Data collected for the study showed that DNR patients were significantly older, more often male than female, and had more co-morbidities or pre-existing conditions.
The authors note one explanation for the higher death rates among COVID-19 patients with DNRs is that the individuals died because they were not resuscitated.
“Another hypothesis is that in the face of rapid clinical deterioration, DNR patients may be more likely to be placed on comfort care (hospice) compared to non-DNR patients,” the authors state. “However, due to the retrospective study design, reasons for a DNR order cannot be determined.”
The study suggests, however, that the DNR status “may be a proxy for more severe illnesses.”
Pressure to Sign
There may be additional possibilities, says Twila Brase, R.N., Ph.N., president and co-founder of Citizens’ Council for Health Freedom, and policy advisor to The Heartland Institute, which co-publishes Health Care News.
“First, hospitals separated Covid-19 patients from their protective families,” Brase said. “How many sick and vulnerable patients felt pressured to sign DNR orders without a family member in their corner?
“Second, the Wall Street Journal reported in December that hospitals initially ventilated patients very early, not for the patient’s benefit, but to try to control the epidemic and save other patients,” Brase said. “Mechanical ventilation is dangerous. Upwards of 80 percent of ventilated patients died. How many scared patients were asked to sign DNR orders before they were sedated and intubated? We’ll never know.”
A report in the U.K’s Daily Mail on December 4 describes such a scenario. A “frailty nursing practitioner” paid a visit to a 93-year old woman who was healthy and living independently. The next day, the woman received a letter with a DNR signed by the official who visited her. The Mail said it received hundreds of similar reports.
A blog on December 8 by the Committee to Unleash Prosperity noted the push to sign DNRs is not unusual when government plays a larger role in health care, as it has with the National Health Service in the U.K.
“We have warned that one inevitable consequence of the march toward government-run health care will be a triage system of death panels to reduce costs – where the government, not families and loved ones decide when to pull the plug,” the blog post states.
Likewise, a report in the Journal of the American Medical Association (JAMA) in March 2020 encouraged health providers to issue unilateral DNRs for patients without their authorization “to reduce the risk of medically futile CPR to patients.”
The report also suggested the use of “informed assent,” instead of “informed consent,” notes Brase. Informed assent is when an individual gives someone authority to make decisions before they become incapacitated.
“This process is used to guide families into not protesting the hospital’s plan to implement a DNR order,” Brase said. “How did this suggestion influence physician discussions with families far from their loved one’s bedside? The study of COVID-19 hospitalizations in New Jersey can be seen as an examination of where such blanket DNR policies can lead.”
The authors of the New Jersey study the push to promote DNR orders for all COVID-19 patients “has created wide public outrage,” because “certifying COVID-19 as the cause of death has driven up statistics of the pandemic and affected healthcare decisions in the U.S. and globally.”
COVID-19 Changes Dynamic
Unlike a terminal illness, where patients and families may have months to consider outcomes, the rapid onset of life-threatening COVID-19 puts families, patients, and physicians in an unusual position, the study notes.
“DNR status may be requested by patients and/or their families to avoid prolonged life support, including application of a respirator, at the end of life when there is little or no expectation that this will be followed by a more normal existence,” the authors state. “Treatment for severe COVID-19 may require such measures as well, but usually for a much shorter interval, days or weeks, usually with a good expectation of a normal or near-normal existence on recovery.”
Bonner R. Cohen, Ph.D., (firstname.lastname@example.org) is a senior fellow at the National Center for Public Policy Research.