Use of do-not-resuscitate orders in patients with kidney disease hospitalized with acute myocardial infarction

Background: Patients with kidney disease are at increased risk for adverse health outcomes in comparison to patients without kidney disease. Therefore, patients with kidney disease may have greater use of do-not-resuscitate (DNR) orders than patients without kidney disease in the setting of an acute illness. We examined the association between advanced kidney disease and use of DNR orders in patients admitted with an acute myocardial infarction (AMI) to all greater Worcester, MA, hospitals as part of an epidemiological study. Methods: Use of DNR orders in 4,033 Worcester residents hospitalized with AMI at 11 greater Worcester medical centers during 1997, 1999, 2001, and 2003 was examined. Advanced kidney disease was defined on the basis of serum creatinine level at the time of hospital admission. Results: Forty-nine percent of patients with kidney disease and AMI had a DNR order in their medical records compared with 21% of patients without kidney disease. After controlling for a variety of potentially confounding factors, patients with kidney disease were more likely to have a DNR order than patients without kidney disease (adjusted odds ratio, 1.55; 95% confidence interval, 1.21 to 1.98). Patients with advanced kidney disease who received DNR orders were older, had more comorbid conditions, and were at greater risk for dying than patients with kidney disease without a DNR order. Conclusion: Advanced kidney disease is associated with greater rates of DNR orders in patients hospitalized with AMI. Awareness of kidney disease may be an important consideration for patients and health care providers in discussing the use of DNR measures.