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The Worcester Heart Attack Study

Elizabeth A. Jackson, MD, MPH; Jorge L. Yarzebski, MD, MPH; Robert J. Goldberg, PhD; Brownell Wheeler, MD; Jerry H. Gurwitz, MD; Darleen M. Lessard, MS; Susanna E. Bedell, MD; Joel M. Gore, MD

Arch Intern Med. 2004;164:776-783.

Background  Coronary heart disease is the leading cause of death in Americans. Despite increased interest in end-of-life care, data regarding the use of do-not-resuscitate (DNR) orders in acutely ill cardiac patients remain extremely limited. The objectives of this study were to describe use of DNR orders, treatment approaches, and hospital outcomes in patients with acute myocardial infarction.

Methods  The study sample consisted of 4621 residents hospitalized with acute myocardial infarction at all metropolitan Worcester, Mass, area hospitals in five 1-year periods from 1991 to 1999.

Results  Significant increases in the use of DNR orders were observed during the study decade (from 16% in 1991 to 25% in 1999). The elderly, women, and patients with previous diabetes mellitus or stroke were more likely to have DNR orders. Patients with DNR orders were significantly less likely to be treated with effective cardiac medications, even if the DNR order occurred late in the hospital stay. Less than 1% of patients were noted to have DNR orders before hospital admission. Patients with DNR orders were significantly more likely to die during hospitalization than patients without DNR orders (44% vs 5%).

Conclusions  The results of this community-wide study suggest increased use of DNR orders in patients hospitalized with acute myocardial infarction during the past decade. Use of certain cardiac therapies and hospital outcomes are different between patients with and without DNR orders. Further efforts are needed to characterize the use of DNR orders in patients with acute coronary disease.

From the Division of Cardiovascular Medicine, Department of Medicine (Drs Jackson, Yarzebski, Goldberg, and Gore and Ms Lessard), and the Department of Surgery (Dr Wheeler), University of Massachusetts Medical School, and Meyers Primary Care Institute (Drs Goldberg and Gurwitz), Worcester; and the Lown Cardiovascular Research Foundation, Brookline, Mass (Dr Bedell). The authors have no relevant financial interest in this article.

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