Black and Hispanic patients experience lower survival rates after in-hospital cardiac arrest (IHCA) than white patients. But a new Yale study suggests that differences in the use of early do-not-attempt-resuscitation (DNAR) orders don’t explain these disparities.
In the study, the researchers did find that Black, Hispanic, and American Indian or Alaska Native patients were significantly less likely than white patients to have DNAR orders — or a medical order instructing a health care team not to restart their heart or breathing if they stop — placed within the first 72 hours following return of spontaneous circulation, or when the heart restarts beating effectively.
And, among this subgroup who did have an early DNAR order, rates of survival until hospital discharge did not differ by race or ethnicity after adjustment. These findings, researchers say, confirm that’s no easy answer behind the disparities in cardiac arrest survival and, thus, requires further research.
“We already know there are persistent racial/ethnic differences in survival after in-hospital cardiac arrest,” said Caroline Raymond-King, an emergency medicine resident at Yale School of Medicine (YSM) and corresponding author of the new study. “One potentially modifiable factor is what happens after return of spontaneous circulation, especially early DNAR orders, which can sometimes be associated with less aggressive post-cardiac arrest care.”
Caroline Raymond-King
“The study was motivated by the question: Could differences in early DNAR use be one contributor to survival gaps after resuscitation?”
The study appears in the journal JAMA Network Open.
Cardiac arrest disparities
Nearly 300,000 people experience in-hospital cardiac arrest (IHCA) annually in the United States. Historically, Black patients have had lower survival rates after IHCA than white patients, even after initial resuscitation. Black patients who achieve return of spontaneous circulation (ROSC) after IHCA are still less likely to survive to hospital discharge than their white counterparts.
One possible determinant of survival, researchers speculated, was differences in the use of DNARs, or medical orders instructing health care teams not to restart their heart or breathing if they stop. DNAR decisions are decided by patients themselves or by a health care proxy in situations where patients cannot make decisions independently.
Early DNAR orders after cardiac arrest aren’t rare. Past research has shown DNAR timing doesn’t always align well with objective prognosis tools; guidelines also recommend waiting at least 72 hours for neurologic prognostication in comatose survivors.
“Prior literature suggests racial differences in advance directives/DNAR decisions exist in other settings, but whether early DNAR after IHCA differs by race/ethnicity — and whether that might relate to survival differences — was unclear,” Raymond-King said.
The research team previously found that women experienced higher rates of DNAR, and early DNAR, setting a precedent to ask this question regarding how race/ethnicity might contribute to the timing of this important medical decision.
To clarify just that, the researchers analyzed data from the American Heart Association’s Get With The Guidelines–Resuscitation (AHA GWTG-R) registry, which includes standardized in-hospital cardiac arrest data from more than 350 U.S. hospitals. Specifically, they examined data for adults aged 18 and older who had experienced IHCA and achieved return of spontaneous circulation while admitted to a hospital during the years 2018 to 2023. (They defined “very early” DNAR as within 12 hours of ROSC and “early” DNAR as within 72 hours.)
Through their methods, the researchers discovered a few things. First, early DNAR is common: About 1 in 4 white patients had DNAR within 12 hours, and 1 in 3 within 72 hours. Second, compared with white patients, Black, Hispanic, and American Indian/Alaska Native patients had lower odds of DNAR orders being placed within 12 hours and within 72 hours — even after adjustment. Third, among that subgroup who did have an early DNAR order, adjusted survival to discharge did not significantly differ by race/ethnicity compared with white patients.
These findings, researchers say, suggest that differences in early DNAR ordering exist by race/ethnicity after IHCA, but early DNAR differences alone are unlikely to explain racial/ethnic survival gaps after IHCA.
“If you’re a clinician, trainee, patient, or family member, the study highlights two practical ideas,” Raymond-King said. “Early DNAR after cardiac arrest is common in U.S. hospitals, so the timing and framing of goals-of-care conversations right after ROSC matters a lot. We still have work to do to understand how to mitigate the survival gap for non-white patients after cardiac arrest.”
This is an important outcome in the pursuit of reducing disparities in cardiac arrest outcomes, said senior author Sarah Perman, an associate professor of emergency medicine at YSM and an AHA GWTG-R research investigator.
“We can now appreciate that this is not an immediate target to remedy in order to better overall outcomes,” she said. “These results do still lend themselves to further investigation, when differences are appreciated it, is always a good opportunity to ask why.”
Other Yale authors include Gail D’Onofrio, the Albert E. Kent Professor of Emergency Medicine, professor of epidemiology (chronic diseases) and professor of medicine core addiction at YSM; Lauren Raymond-King, hospital resident at YSM; and Xunyun Wan, a recent graduate in biostatistics in Yale’s Graduate School of Arts and Sciences.
The study was supported by grants from Emergency Medicine Foundation and National Heart Lung and Blood Institute.
