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Impact of frailty on do-not-resuscitate orders and healthcare transitions among elderly Koreans with pneumonia

Authors Choi JY, Kim SW, Yoon SJ, Kang MG, Kim KI, Kim CH

Received 25 July 2018

Accepted for publication 22 September 2018

Published 1 November 2018 Volume 2018:13 Pages 2237—2245

DOI https://doi.org/10.2147/CIA.S181400

Checked for plagiarism Yes

Review by Single-blind

Peer reviewers approved by Dr Amy Norman

Peer reviewer comments 2

Editor who approved publication: Dr Richard Walker


Jung-Yeon Choi,1 Sun-wook Kim,1 Sol-Ji Yoon,2 Min-gu Kang,1 Kwang-il Kim,1 Cheol-Ho Kim1

1Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam 463-707, Republic of Korea; 2Department of Internal Medicine, Kangwon National University Hospital Gangwon-Do 200-722, Republic of Korea

Purpose: Pneumonia poses a significant health risk in aging societies. We aimed to elucidate the determinative value of frailty for do-not-resuscitate (DNR) orders in pneumonia patients.
Patients and methods:
This was a retrospective cohort study conducted at the Seoul National University Bundang Hospital (SNUBH) in Korea. Medical records of 431 pneumonia patients, aged 65 years and older, who were admitted between June 2014 and May 2015 were analyzed. Patients were categorized into DNR and no-DNR groups.
Results: Among the 65 patients (15.1% of pneumonia patients) who completed DNR documents, 24 patients were survived, and 21 patients decided imminent to death (<24 hours before death), with all decisions determined by surrogates. The DNR group tended to be older and frail, with higher rates of renal impairment and malnutrition, and had a lower microbiology detection effort than the no-DNR group. The DNR group used a high number of broad-spectrum antibiotics, experienced high levels of in-hospital (63.1% vs 5.7%, P<0.001) and 30-day (64.6% vs 9.6%, P<0.001) mortality rates, and had prolonged hospital stays (median length of hospital stay, 12 vs 9 days, P=0.020). Frailty was independently associated with DNR status even after adjustment for sepsis, septic shock, and the pneumonia severity index (PSI) score. Frailty also significantly influenced healthcare setting transitions after adjustment for sepsis, septic shock, and the PSI.
Conclusion: We identified the factors associated with DNR orders and their prognoses among elderly Koreans with pneumonia. Frailty was significantly associated with DNR decision and healthcare setting transitions in pneumonia patients.

Keywords: do-not-resuscitate, end-of-life care, frailty index

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