The NHS Outcomes framework classes respiratory deaths in those aged under 75 as potentially avoidable. In practise the level of care available is often limited in those who are unlikely to benefit from invasive interventions which may limit death ‘avoidability’. We sought the frequency of such limitations by investigation of the use of ‘Do not actively resuscitate’ (DNAR) orders in adults with pneumonia.
Adult admissions for pneumonia (ICD10 J12-J18) to one NHS Trust between 01/01/2012 and 31/05/2012 were retrospectively identified. Case details were gleaned from the case records.
293 cases were found of which 81 (28%) died. After exclusions (no radiographic pneumonia (12), no radiograph within 24 hours (1) and no radiograph (1)), 67 deaths remained. From these, 20 case notes were obtained and compared with the 40 subsequent surviving admissions. DNAR orders were present in 18 (30%) cases. 11 DNAR orders were recorded within 48 hours of admission, 2 within the next 48 hours and 5 in the following 5 days. They were more frequent in those who died (13/20 – 65%) than those that survived (5/40 – 12.5%; p<0.001). There was a non-significant trend for DNAR to be less frequent in those ≤75 (6/31 – 33%) than those aged >75 (12/29 – 67%; p=0.091) and they were more frequent in those admitted from nursing homes (5/7 – 71.4%) than from their own home (9/49 – 18.4%; p<0.001). 11/60 (18.3%) were admitted to ICU but patients with DNAR were no more or less likely to be so managed (5/18 – 27.8% cf 6/42 – 14.3%; p=0.279). There was a trend for DNAR to have been recorded more often in the more severely ill. Rates by CURB65 score were 0 – 1/5 (20%), 1 – 2/17 (11.8%), 2 – 3/15 (20%), 3 – 8/17 (47.1%), 4 – 3/5 (60%), 5 – 1/1 (100%); p=0.063.
The high frequency of DNAR orders suggests that pneumonia deaths may not be as preventable as might be considered at first sight. This may be especially true for those aged >75. In any assessment of the predictability of death the use of DNAR orders should be considered.
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