# Race and Ethnicity and Early Do Not Attempt Resuscitation Orders After In-Hospital Cardiac Arrest

## TL;DR

The study found that American Indian, Black, and Hispanic patients were less likely to have early do not attempt resuscitation orders after in-hospital cardiac arrest compared to White patients, but survival rates were similar among those with early orders.

## Contribution

The study reveals racial and ethnic disparities in early DNAR order placement after in-hospital cardiac arrest, with no survival differences among those with early orders.

## Key findings

- American Indian, Black, and Hispanic patients were less likely to have early DNAR orders than White patients.
- Survival to hospital discharge was similar among patients with early DNAR orders across racial and ethnic groups.
- Disparities in DNAR order placement persisted even after adjusting for clinical factors.

## Abstract

Do American Indian or Alaskan Native, Black, or Hispanic patients have different rates of early do not attempt resuscitation (DNAR) orders compared with White patients after in-hospital cardiac arrest?

In this cohort study including 93 843 patients from more than 350 hospitals, American Indian or Alaska Native, Black, and Hispanic patients were less likely to have early DNAR orders entered, compared with White patients; those with early orders had no difference in survival to discharge compared with White patients.

This cohort study found that after in-hospital cardiac arrest, American Indian or Alaska Native, Black, and Hispanic patients were less likely to have early DNAR orders than White patients, and there were no differences in survival among patients with early DNAR orders placed.

This cohort study examines whether American Indian or Alaskan Native, Black, or Hispanic patients had different rates of early do not attempt resuscitation (DNAR) orders compared with White patients and whether survival differences by race and ethnicity persisted among patients with early entry of DNAR orders.

Black and Hispanic patients have lower survival rates for in-hospital cardiac arrest (IHCA) than White patients. Whether this is because do not attempt resuscitation (DNAR) orders for successfully resuscitated patients with IHCA are variable among different races and ethnicities remains unknown.

To understand whether American Indian or Alaskan Native, Black, or Hispanic patients have different rates of early DNAR orders compared with White patients, and to examine whether survival differences by race and ethnicity persist among patients with early entry of DNAR orders.

This prospective cohort study used data from the American Heart Association’s Get With the Guidelines – Resuscitation database, which includes IHCA data from more than 350 hospitals in the US from 2018 to 2013. Patients were aged at least 18 years, experienced an index IHCA, and were successfully resuscitated while on an admitted unit. Data were analyzed from September 26, 2024, through February 8, 2025.

IHCA.

Main outcomes were associations of race and ethnicity with entry of early DNAR orders and, among patients early DNAR orders, the associations of race with survival to hospital discharge.

From 2018 to 2023, 93 843 patients (25 386 patients [27.1%] aged 60-69 years; 56 533 [60.2%] male) achieved ROSC after IHCA, including 2380 American Indian or Alaska Native patients (2.5%), 764 Asian patients (0.8%), 21 261 Black patients (22.7%), 6998 Hispanic patients (7.5%), and 56 989 White patients (60.7%). Overall, 25.3% and 37.4% of White patients had DNAR orders at 12 hours and 72 hours, respectively, compared with 21.3% and 33.4% of American Indian or Alaska Native patients, 21.4% and 32.7% of Black patients, and 22.2% and 33.2% of Hispanic patients. Compared with White patients, American Indian or Alaska Native, Black, and Hispanic patients were less likely to have DNAR orders entered within 12 hours (American Indian or Alaska Native: odds ratio [OR], 0.78 [95% CI, 0.67-0.91]; Black: OR, 0.74 [95% CI, 0.69-0.79]; Hispanic: OR, 0.90 [95% CI, 0.82-0.99]) or within 72 hours (American Indian or Alaska Native: OR. 0.86 [95% CI, 0.76, 0.98]; Black: OR, 0.73, [95% CI, 0.69-0.77]; Hispanic: OR, 0.89 [95% CI, 0.83, 0.97]). A total of 813 American Indian or Alaska Native patients (34.2%), 7168 Black patients (33.7%), and 2417 Hispanic patients (34.5%) with return of spontaneous circulation survived to discharge, compared with 22 226 White patients (39.0%). In adjusted analyses, among patients with an early DNAR order entered before 72 hours, there was no significant difference in survival to hospital discharge compared with White patients.

In this cohort study of patients successfully resuscitated from IHCA, American Indian or Alaska Native, Black, and Hispanic patients were less likely to have early DNAR orders than White patients. There were no differences in survival among patients with early DNAR orders placed.