Internal Medicine, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, 08901, United States.
Division of Gastroenterology and Hepatology, Robert Wood Johnson School of Medicine, Rutgers Biomedical and Health Sciences (RBHS), Rutgers University, New Brunswick, NJ, 08901, United States.
Ann Hepatol. 2021 May-Jun;22:100284. doi: 10.1016/j.aohep.2020.10.012. Epub 2020 Nov 4.
Decompensated cirrhosis carries high inpatient morbidity and mortality. Consequently, advance care planning is an integral aspect of medical care in this patient population. Our study aims to identify do-not-resuscitate (DNR) order utilization and demographic disparities in decompensated cirrhosis patients.
Nationwide Inpatient Sample was used to extract the cohort of patients from January 1st, 2016 to December 31st, 2017, based on the most comprehensive and recent data. The first cohort included hospitalized patients with decompensated cirrhosis. The second cohort included patients with decompensated cirrhosis with at least one contraindication for liver transplantation.
A cohort of 585,859 decompensated cirrhosis patients was utilized. DNR orders were present in 14.2% of hospitalized patients. DNR utilization rate among patients with relative contraindication for liver transplantation was 15.0%. After adjusting for co-morbid conditions, disease severity, and inpatient mortality, African-American and Hispanic patient populations had significantly lower DNR utilization rates. There were regional, and hospital-level differences noted. Moreover, advanced age, advanced stage of decompensated cirrhosis, inpatient mortality, and relative contraindications for liver transplantation (metastatic neoplasms, dementia, alcohol misuse, severe cardiopulmonary disease, medical non-adherence) were independently associated with increased DNR utilization rates.
The rate of DNR utilization in patients with relative contraindications for liver transplantation was similar to patients without any relative contraindications. Moreover, there were significant demographic and hospital-level predictors of DNR utilization. This information can guide resource allocation in educating patients and their families regarding prognosis and outcome expectations.
失代偿性肝硬化患者具有较高的住院发病率和死亡率。因此，预先护理计划是该患者群体医疗护理的一个组成部分。我们的研究旨在确定失代偿性肝硬化患者的不复苏（DNR）医嘱的使用情况和人口统计学差异。
使用全国住院患者样本，根据最全面和最新的数据，从 2016 年 1 月 1 日至 2017 年 12 月 31 日提取患者队列。第一队列包括失代偿性肝硬化住院患者。第二队列包括至少有一种肝移植相对禁忌证的失代偿性肝硬化患者。
利用了 585859 名失代偿性肝硬化患者的队列。14.2%的住院患者有 DNR 医嘱。肝移植相对禁忌证患者的 DNR 使用率为 15.0%。在调整了合并症、疾病严重程度和住院死亡率后，非裔美国人和西班牙裔患者人群的 DNR 使用率明显较低。还注意到了区域和医院层面的差异。此外，年龄较大、失代偿期较晚、住院死亡率以及肝移植的相对禁忌证（转移性肿瘤、痴呆、酒精滥用、严重心肺疾病、医疗不依从）与 DNR 使用率的增加独立相关。
肝移植相对禁忌证患者的 DNR 使用率与无任何相对禁忌证患者相似。此外，DNR 使用存在显著的人口统计学和医院层面的预测因素。这些信息可以指导在教育患者及其家属有关预后和结果预期方面的资源分配。
