MedWire News: Do not resuscitate (DNR) orders may impact on the treatment of patients hospitalized with acute heart failure (HF), US research has revealed.

DNR orders typically specify withholding cardiopulmonary resuscitation, but the implications of these orders can be broadly interpreted, say Joline Chen (Boston University School of Medicine, Massachusetts) and co-workers.

In an observational study, they examined the impact of DNR orders by reviewing the medical records of 4537 patients hospitalized with clinical findings of decompensated HF in one of 11 central Massachusetts hospitals from 1995 to 2000.

Approximately 30% of patients had a DNR order placed in their hospital chart at any time during the short-term hospitalization.

Patients with DNR orders were less likely than those without such orders to have had their left ventricular function assessed (31% vs 43%), or to receive renin-angiotensin system blockade (49% vs 57%), anticoagulation (65% vs 78%), or nonpharmacologic interventions (87% vs 92%).

Those with DNR orders were also significantly less likely than others to receive any quality assurance measure for acute HF, with an adjusted hazard ratio 0.63.

"A key finding of our study was that, while not optimal, most patients with or without a DNR order received at least one treatment strategy appropriate for the management of acute HF," the authors acknowledge in the American Heart Journal.

"However, the proportion of patients who received all indicated performance measures was low."

In particular, Chen et al note that counselling rates for smoking cessation were low and were "identified as an area that will need improvement in the more effective management of patients hospitalized for HF."

They conclude: "Physicians and patients alike should be aware of the significance of having a DNR order and its potential implications that may modify the course of treatment."

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