# Do-Not-Attempt-Resuscitation Orders in Older Adult Patients With Out-of-Hospital Cardiac Arrest: A Single-Center Retrospective Study at an Urban University Hospital Emergency Department in Japan

## TL;DR

This study examines how often do-not-attempt-resuscitation orders are used for older adults in Japan and finds they are rare and often misunderstood.

## Contribution

The study provides new insights into DNAR order usage and challenges in an aging Japanese population.

## Key findings

- Only 16% of older patients had DNAR orders, and 26% of these had CPR continued despite the orders.
- Delays and misunderstandings about DNAR orders were common reasons for continuing resuscitation.
- Older age, male sex, and nursing home residence were linked to higher DNAR order requests.

## Abstract

Introduction

Despite its super-aging society, advance directives or physician orders for life-sustaining treatment are uncommon in Japan. This study aimed to determine the incidence of do-not-attempt-resuscitation (DNAR) orders in older adult patients with out-of-hospital cardiac arrest in Japan and whether cardiopulmonary resuscitation was canceled based on these orders.

Methods

We retrospectively analyzed patients with out-of-hospital cardiac arrest aged ≥65 years who were transported to and treated at Keio University Hospital emergency department between January 1, 2016, and December 31, 2018. Patients with in-hospital cardiac arrest, those treated by clinical departments other than the emergency department, and those transported from other hospitals were not included. We assessed the rate of DNAR orders and cardiopulmonary resuscitation terminations in patients in the emergency department with DNAR orders.

Results

Among the 142 included patients, 23 (16%) had not attempted resuscitation orders made by the patients or family members. Of these, six (26%) underwent continued cardiopulmonary resuscitation despite their DNAR orders. The reasons for continuing cardiopulmonary resuscitation were delays in confirming the DNAR orders and problems in understanding the DNAR orders. Patients of higher age, male sex, nursing home admission, and continued medical examination at our hospital were significantly more likely to desire DNAR orders.

Conclusions

In Japan, the number of DNAR orders among older adults is low. Furthermore, these orders are not sufficiently understood, even by medical workers. Thus, increased medical and social awareness of advance directives and physician orders for life-sustaining treatment is needed.