Changes in the Use of Do-not-resuscitate Orders After Implementation of the Patient Self-determination Act

OBJECTIVE: To determine changes in the use of do-not-resuscitate (DNR) orders and mortality rates following a DNR order after the Patient Self-determination Act (PSDA) was implemented in December 1991. DESIGN: Time-series. SETTING: Twenty-nine hospitals in Northeast Ohio. PATIENTS/PARTICIPANTS: Medicare patients (N = 91,539) hospitalized with myocardial infarction, heart failure, gastrointestinal hemorrhage, chronic obstructive pulmonary disease, pneumonia, or stroke. MEASUREMENTS AND MAIN RESULTS: The use of “early” (first 2 hospital days) and “late” DNR orders was determined from chart abstractions. Deaths within 30 days after a DNR order were identified from Medicare Provider Analysis and Review files. Risk-adjusted rates of early DNR orders increased by 34% to 66% between 1991 and 1992 for 4 of the 6 conditions and then remained flat or declined slightly between 1992 and 1997. Use of late DNR orders declined by 29% to 53% for 4 of the 6 conditions between 1991 and 1997. Risk-adjusted mortality during the 30 days after a DNR order was written did not change between 1991 and 1997 for 5 conditions, but risk-adjusted mortality increased by 21% and 25% for stroke patients with early DNR and late DNR orders, respectively. CONCLUSIONS: Overall use of DNR orders changed relatively little after passage of the PSDA, because the increase in the use of early DNR orders between 1991 and 1992 was counteracted by decreasing use of late DNR orders. Risk-adjusted mortality rates after a DNR order generally remained stable, suggesting that there were no dramatic changes in quality of care or aggressiveness of care for patients with DNR orders. However, the increasing mortality for stroke patients warrants further examination

Arrival date and territorial behavior are associated with corticosterone metabolite levels in a migratory bird

International audienceGlucocorticoids promote the mobilization of energy stores and they may facilitate the expression of energetically expensive functions. Early arrival on the breeding grounds in migratory species and territorial competition are energetically demanding activities that may be supported by elevated baseline glucocorticoid levels. Here, we evaluated the associations between the baseline levels of excreted corticosterone (CORT) metabolites of male Pied Flycatchers () just after arriving on their breeding area and timing of arrival, considering ornamental traits indicative of social status, like forehead patch size and black plumage coloration, as well as heat shock protein levels (HSP60). We observed a positive association of CORT metabolites with HSP60 levels, which are synthesized under several environmental challenges affecting cell homeostasis. Our data showed a negative association between arrival date and CORT metabolite levels, possibly as a result of the higher energetic demands imposed by the hard environmental conditions experienced at the time of an early arrival after migration. We observed a negative relationship of forehead patch dimensions and CORT metabolite levels, suggesting that dominance is associated with low baseline CORT metabolites. Also, males that expressed a higher degree of territorial behaviour when exposed to a playback song of a conspecific at their nest-box showed higher CORT metabolites upon arrival than males that expressed a lower degree of territorial behavior. This may indicate that elevated baseline CORT metabolite levels may facilitate an intense territorial competition in males. Thus, male–male competition may be a factor affecting observed baseline glucocorticoid levels in migratory birds