Following the retraction of a Johns Hopkins study that showed overall deaths in the United States had not really increased with the COVID-19, researchers have produced another analysis that is interesting to note. In a retrospective study of patients hospitalized with COVID-19 in New Jersey, 89% had a do-not-resuscitate (DNR) order before admission.
The significance of DNR status as an independent risk factor for mortality has not been documented previously in COVID19 patients. The present study analyzed data of 1270 patients with COVID-19, who were admitted to our institutions during the peak of the COVID-19 pandemic in New Jersey. DNR patients had higher hazard ratios for risk of death and lower survival outcomes compared to non-DNR patients. The association between DNR status and poor clinical outcomes remained independently significant after adjustment for important clinical factors, including age, gender, COVID-19 symptoms at the time of admission and comorbidities.
DNRs are not the same as living wills, healthcare proxies, or powers of attorney, where an individual may give another individual the power to make medical decisions for them if they become unable to do so. Rather, DNRs are signed by a physician and direct all medical staff not to revive an individual should he go into cardiac arrest.
Often DNR orders will include a prohibition of lifesaving measures for respiratory arrest, including mechanical ventilation. A physician issues a DNR in consultation with a patient and his loved ones. This generally follows a prognosis in clinical practice where medical estimates determine the patient has a terminal condition. Resuscitation would prolong suffering or result in a poor quality of life.
Having worked in hospice and other clinical practice areas with the severely ill, I can assure you these orders are not made lightly. Nor do they preclude medical staff from providing palliative care such as antibiotics, steroids, oxygen, pain medication, and other treatments to increase a patient’s comfort.
This study is notable because it indicates that many patients who died in these hospitals were quite ill to begin with. If this trend held in larger samples of the national population, at least one prediction made by Imperial College researcher Neil Ferguson may bear out. When he revised his statistics, he told officials in the U.K. that a significant portion of COVID-19 deaths in the country would likely have happened within the next six to twelve months without the virus:
“We don’t know what the level of excess deaths will be in this epidemic,” Ferguson said. In other words, we don’t know the extent to which COVID-19 will increase annual deaths above the level that otherwise would have been expected. “By the end of the year, what proportion of those people who’ve died from COVID-19 would have died anyhow?” Ferguson asked. “It might be as much as half to two-thirds of the deaths we’re seeing from COVID-19, because it’s affecting people who are either at the end of their lives or in poor health conditions. So I think these considerations are very valid.”
While Ferguson noted that this calculation based on years of life might sound overly utilitarian, it was an important component of determining public policy when considering the drastic economic impact of locking down and quarantining the healthy.
This initial data from New Jersey is indicative that Ferguson’s estimates were in the ballpark. It also indicates that COVID-19 is acting as bacterial and viral pneumonia often do in this population. It is a contributing factor in a patient’s death, but one of many.
This trend deserves a broader study. The presence of a DNR is more enlightening than a simple analysis of comorbidities because it is indicative of disease severity. However, when you combine it with recent data from the WHO that estimates the infection fatality rate (IFR) of COVID-19 at 0.13%, a complete reconsideration of public policy related to quarantining the healthy, testing the asymptomatic, and other measures is warranted.