Factors associated with "do not resuscitate" orders and rates of withdrawal from hemodialysis in the international DOPPS.

Background: Worldwide statistics on practice patterns regarding "do not resuscitate" (DNR) orders and patient withdrawal from hemodialysis have not been uniformly collected or analyzed.

Methods: Using data concerning adult hemodialysis patients randomly selected from 308 representative dialysis facilities in France, Germany, Italy, Japan, Spain, the United Kingdom, and the United States participating in the Dialysis Outcomes and Practice Patterns Study, DNR orders were tabulated at study entry from a prevalent cross-section of patients (N = 8615), using multivariate logistic regression to investigate characteristics associated with DNR status, Cox models to identify risk factors for withdrawal from hemodialysis, and scores from the mental component summary (MCS) and physical component summary (PCS) of the SF-36 to assess health-related quality of life.

Results: The United States had the highest prevalence of DNR orders (7.5%) and rate of withdrawal from hemodialysis (3.5 per 100 patient-years). Significant and independent associations with higher odds ratio (OR) of DNR were observed for older age (OR 1.16 per 10 years higher, P = 0.03) and nursing home residence (OR 2.34, P = 0.003), and with higher relative risk (RR) of withdrawal from dialysis (RR 2.38, P < 0.001). Patients who withdrew from hemodialysis died within a mean of 7.8 days and a median of 6.0 days.

Conclusion: The higher prevalence of DNR and rate of withdrawal from hemodialysis in the United States are consistent with its greater legal and cultural emphasis on patient autonomy. By showing characteristics associated with these outcomes, this study contributes to our understanding of why hemodialysis patients request DNR or withdraw from treatment.