Mortality from COVID-19 has been particularly high in elderly patients on mechanical ventilation. Treatment outcomes for patients with do-not-intubate (DNI) status are unknown. One hundred patients admitted to the non-ICU ward during the “first wave” were retrospectively analyzed. 

E. (Els) van Nood

Ingrid C. de Backer

J.G.J.V. (Joachim) Aerts

M.M. (Menno) van der Eerden

M.S. (Marthe) Paats

Simone van der Sar-van der Brugge

T. (Tjeerd) van der Veer

Mortality from COVID-19 has been particularly high in elderly patients on mechanical ventilation. Treatment outcomes for patients with do-not-intubate (DNI) status are unknown. One hundred patients admitted to the non-ICU ward during the \xe2\x80\x9cfirst wave\xe2\x80\x9d were retrospectively analyzed. Mortality rate was 49% in patients with a DNI order. This subgroup was characterized by significantly higher age, more comorbidity, and care dependency. Mortality among DNI patients was three times higher than other patients, but not higher than some of the published mortality rates for elderly mechanically ventilated patients. Advanced care planning is essential in COVID-19 to assist patient autonomy and prevent non-beneficial medical interventions.</p

Erasmus University Digital Repository

Do-not-intubate status and COVID-19 mortality in patients admitted to Dutch non-ICU wards

Mortality from COVID-19 has been particularly high in elderly patients on mechanical ventilation. Treatment outcomes for patients with do-not-intubate (DNI) status are unknown. One hundred patients admitted to the non-ICU ward during the “first wave” were retrospectively analyzed. Mortality rate was 49% in patients with a DNI order. This subgroup was characterized by significantly higher age, more comorbidity, and care dependency. Mortality among DNI patients was three times higher than other patients, but not higher than some of the published mortality rates for elderly mechanically ventilated patients. Advanced care planning is essential in COVID-19 to assist patient autonomy and prevent non-beneficial medical interventions

van der Veer, Tjeerd

van der Sar-van der Brugge, Simone

Paats, Marthe S.

van Nood, Els

de Backer, Ingrid C.

Aerts, Joachim G.J.V.

van der Eerden, Menno M.

NARCIS 

Mortality from COVID-19 has been particularly high in elderly patients on mechanical ventilation. Treatment outcomes for patients with do-not-intubate (DNI) status are unknown. One hundred patients admitted to the non-ICU ward during the “first wave” were retrospectively analyzed. Mortality rate was 49% in patients with a DNI order. This subgroup was characterized by significantly higher age, more comorbidity, and care dependency. Mortality among DNI patients was three times higher than other patients, but not higher than some of the published mortality rates for elderly mechanically ventilated patients. Advanced care planning is essential in COVID-19 to assist patient autonomy and prevent non-beneficial medical interventions.</p

EUR Research Repository

BRIEF REPORTDo-not-intubate status and COVID-19 mortality in patients admittedto Dutch non-ICU wardsTjeerd van der Veer1 & Simone van der Sar-van der Brugge2 & Marthe S. Paats1 & Els van Nood3,4 &Ingrid C. de Backer2 & Joachim G. J. V. Aerts1 & Menno M. van der Eerden1Received: 18 December 2020 /Accepted: 8 March 2021# The Author(s) 2021AbstractMortality from COVID-19 has been particularly high in elderly patients on mechanical ventilation. Treatment outcomes forpatients with do-not-intubate (DNI) status are unknown. One hundred patients admitted to the non-ICU ward during the “firstwave” were retrospectively analyzed. Mortality rate was 49% in patients with a DNI order. This subgroup was characterized bysignificantly higher age, more comorbidity, and care dependency. Mortality among DNI patients was three times higher thanother patients, but not higher than some of the published mortality rates for elderly mechanically ventilated patients. Advancedcare planning is essential in COVID-19 to assist patient autonomy and prevent non-beneficial medical interventions.Keywords COVID-19 . Mechanical ventilation . Elderly medicine . Respiratory intensive care . Viral respiratory infection .Advance care planningIntroductionIn-hospital mortality rates due to COVID-19 have primarilybeen determined by ICU mortality. In the first months of thepandemic, there was an average 42% risk of mortality whenadmitted to the ICU [1], while overall mortality of hospital-ized patients was around 20% [2, 3]. Mortality is particularlyhigh for mechanical ventilation at older age [1–3]. Some el-derly and/or frail patients are not admitted to the ICU formechanical ventilation and remain on the non-ICU ward forconservative treatment. In the Netherlands, advance directivessuch as a do-not-intubate (DNI) order are required to bediscussed with the patient and/or relatives upon admission.To characterize a group of patients in whom a DNI statuswas chosen upon admission and to compare outcomes withpatients without treatment restrictions, we analyzed 100 pa-tients admitted to the non-ICU COVID-19 wards.MethodsThe Erasmus MC is the Netherlands’ largest university hospi-tal, and Amphia Hospital is a large teaching hospital. In thisretrospective analysis, we reviewed the files of 100 patients(the first 50 patients per center) admitted to the dedicated non-ICU COVID-19 wards, with admission dates between 17March and 23 April 2020. Cases of COVID-19 were all con-firmed by real-time PCR of nasopharyngeal swabs. Of these100 patients, patient characteristics, clinical signs and symp-toms, comorbidities, treatment, and outcomes were comparedbetween patients with and without a DNI order. Comorbiditieswere scored using Charlson comorbidity index (CCI) [4].ResultsOf 100 patients, the average age was 68 years, body massindex (BMI) was 27, and 67% of the patients were male. Ofthese patients, 82% had at least one pre-existing comorbidity,with an average Charlson comorbidity index (CCI) of 4.2points (see Table 1).* Tjeerd van der Veert.vanderveer@erasmusmc.nl1 Department of Pulmonary Medicine, Erasmus MC, Rotterdam, theNetherlands2 Department of Pulmonary Medicine, Amphia Hospital, Breda, theNetherlands3 Department of Internal Medicine, Erasmus MC, Rotterdam, theNetherlands4 Department of Medical Microbiology and Infectious Diseases,Erasmus MC, Rotterdam, the Netherlandshttps://doi.org/10.1007/s10096-021-04223-4/ Published online: 12 March 2021European Journal of Clinical Microbiology & Infectious Diseases (2021) 40:2207–2209For 39 patients (39%), a DNI order was noted in the patientfile. In 29/39 patients (74%), the DNI status was chosen atadmission after counselling by the attending physician. For 8/39 patients (21%), the DNI status had already been chosenpreviously. For two patients (5%), the DNI status was decidedduring hospital stay after confirmation of COVID-19 diagno-sis because of expected poor prognosis of mechanical venti-lation for COVID-19 pneumonia. The reported reasons tochoose a DNI status were combined frailty, multimorbidity,and age (23/39, 59%); the patient’s explicit wish (5/39, 13%);severe neurologic comorbidity (3/39, 7.5%); active malignan-cy (2/39, 5%); cardiac comorbidity (2/39, 5%); pulmonarycomorbidity (1/39, 3%); and severe cognitive impairment(3/39, 7.5%).Patients with a DNI status were significantly older in com-parison with patients without a DNI status, (77.0 vs. 62.2years, p<0.01), had more comorbidities resulting in a signifi-cantly higher CCI (6.2 vs. 2.9 points, p<0.01), and lived sig-nificantly less often at home unassisted (69.2% vs. 96.7%,p<0.01) (see Table 1).Overall mortality rate was 29%. Outcomes differed signif-icantly between DNI and non-DNI status groups. Among pa-tients with a DNI status, mortality was 48.7%. No DNI statuspatients were later transferred to the ICU. Among patientswithout a DNI status, mortality was 16.4%. Of this group,16 patients (26.2%) were admitted to the ICU for mechanicalventilation when their condition deteriorated, of which 10/16patients died (62.5%) (see Table 1).Patient symptoms at admission were not significantly dif-ferent, except for the reported number of days since onset ofsymptoms, which was significantly higher for the group with-out DNI status. Initial treatment did not differ significantlybetween groups. All patients were treated with oxygen sup-pletion by nasal cannula or non-rebreathing oxygen masks.During this period, no high-flow nasal oxygen devices wereused because of concerns of COVID-19 spread through aero-solization. All patients received empiric treatment with broadspectrum antibiotics. A minority of cases received either ste-roids or hydroxychloroquine, with no significant differencesfor comparison between DNI and non-DNI groups. (Of note,these patients were admitted before the beneficiary effects ofsteroids were known [5] and before implementation of stan-dard high prophylactic antithrombotic medication.)DiscussionPatients with severe COVID-19 are often transferred to theICU for mechanical ventilation. However, in some circum-stances, patients are not eligible for invasive mechanical ven-tilation, because of their own wishes or severe comorbidityand/or frailty. Mortality rates for this category of patients haveTable 1 Characteristics,symptoms, treatment andoutcomes of patients admitted tothe non-ICU COVID wardsPatient characteristics DNI (n= 39) Non-DNI (n=61) Total (n= 100)Age* 77.0 years ± 9.2Range 61–9462.2 years ± 13.2Range 21–8568.0 years ± 13.8Range 21–94BMI 26.7 ± 5.8 27.2 ± 4.6 27.0 ± 5.1Male/female 67%/33% 67%/33% 67%/33%Charlson comorbidity index* 6.2 ± 2.3 2.9 ± 2.2 4.2 ± 2.7Any kind of chronic comorbidity* 97.4% 73.8% 82%Living at home unassisted* 69.2% 96.7% 86%Living with care at home* 18% 3.3% 9%Living at care facility* 12.8% 0% 5%OutcomesMortality* 48.7% (19/39) 16.4% (10/61) 29% (29/100)Admission until discharge (survivors), days 10.4 ± 5.8 10.1 ± 8.1 10.2 ± 7.5Discharge to home vs. other care facility * 40%/60% 82.4%/17.6% 70.4%/29.6%Admission until death (deceased), days† 6.7 ± 4.7 12.1 ± 7.2 8.6 ± 6.1Symptom onset to admission, days* 4.7 ± 3.9 9.7 ± 4.8 7.8 ± 5.1Symptoms and treatment at admissionDyspnea 69.2% 82.0% 77.0%Temp ≥38.0 59.0% 73.8% 68.0%Oxygen suppletion at admission 61.5% 54.1% 57.0%Treatment with steroids 10.3% 14.8% 13.0%Hydroxychloroquine 33.3% 45.9% 41.0%*p< 0.01 for comparison between DNI and non-DNI groups. †p<0.05 for comparison between DNI and non-DNIgroups. p-values calculated using t-test and chi-square test2208 Eur J Clin Microbiol Infect Dis (2021) 40:2207–2209not yet been published. Our retrospective study shows thatmortality rates were very high for this category of patients(48.7%) and three times higher than patients without DNIstatus admitted to the same wards in the same period. It is alsoabout two times higher than overall COVID-19 mortality inour hospitals during the same time period (circa 25%, unpub-lished data) and “first wave”mortality rates in the literature [2,3]. Compared to the non-DNI group, patients with a DNIstatus had significantly higher age and had more comorbidity,which are known risk factors for COVID-19-related mortality.DNI patients were on average 77 years old with an averageCCI score of 6.2, which indicates multiple comorbidities andan estimated 10-year survival of 0–2%. Mortality rates report-ed for invasively ventilated patients in this age group inGermany were even higher at 63% (70–79 years) and 72%(patients over 80 years), whereas mortality in non-invasivelyventilated patients was 45% [2]. In another analysis of octo-genarian patients, premorbid frailty was an important prog-nostic factor, and ICU treatment did not improve outcomesin fit nor frail patients [6]. Compared with these figures, thereis no sign that mortality rates for our patients have been neg-atively impacted by the DNI policies.Remarkably, only 5 patients were living at a nursing homeprior to admission. In all those patients, a DNI status was or-dered. Many nursing home residents with COVID-19 havebeen cared for in their facility and were not referred to thehospitals. Advanced care planning including patient’s viewson resuscitation, intubation, and referral to hospitals are routinepractice in Dutch nursing homes, allowing optimal attention topalliative care where indicated and prioritization of advancedmedical care to the patients with greatest benefit. Although totalcapacity and logistics of ICU beds for COVID-19 patients be-came a topic of national interest during the weeks of peakincidence, there was no “black list” for triaging ICU access.In our cohort, ICU capacity was available for all eligible pa-tients, and all DNI orders were chosen after counselling withpatients and/or their relatives. In recently published guidanceon advanced care planning in COVID-19, this practice has beenrecommended as standard care [7, 8].In conclusion, during the peak of the COVID-19 outbreakin the Netherlands, mortality in the dedicated non-ICUCOVID-19 wards of our centers was high, especially in pa-tients who had a DNI status. This group of patients was char-acterized by old age, high burden of comorbidities, andassisted living or nursing home residency. Advanced careplanning is essential in COVID-19 to assist patient autonomyand prevent non-beneficial medical interventions.Data Availability (data transparency) The datasets generatedduring and/or analyzed during the current study are availablefrom the corresponding author on reasonable request.Code availability Not applicableDeclarationsEthics approval Approval was obtained from the Erasmus MC andAmphia medical ethical boardConsent to participate and publication Consent was obtained from allparticipants and/or representatives.Conflict of interest The authors declare no competing interests.Open Access This article is licensed under a Creative CommonsAttribution 4.0 International License, which permits use, sharing, adap-tation, distribution and reproduction in any medium or format, as long asyou give appropriate credit to the original author(s) and the source, pro-vide a link to the Creative Commons licence, and indicate if changes weremade. The images or other third party material in this article are includedin the article's Creative Commons licence, unless indicated otherwise in acredit line to the material. If material is not included in the article'sCreative Commons licence and your intended use is not permitted bystatutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of thislicence, visit http://creativecommons.org/licenses/by/4.0/.References1. Armstrong RA, Kane AD, Cook TM (2020) Outcomes from inten-sive care in patients with COVID-19: a systematic review and meta-analysis of observational studies. Anaesthesia 75(10):1340–13492. Karagiannidis C et al (2020) Case characteristics, resource use, andoutcomes of 10 021 patients with COVID-19 admitted to 920German hospitals: an observational study. Lancet Respir Med 8(9):853–8623. Richardson S, Hirsch JS, Narasimhan M (2020) Presenting charac-teristics, comorbidities, and outcomes among 5700 patients hospital-ized with COVID-19 in the New York City Area (Apr, 10.1001/jama.2020.6775, 2020). Jama-J AmMed Assoc 323(20):2098–20984. Charlson ME et al (1987) A new method of classifying prognosticcomorbidity in longitudinal studies: development and validation. JChronic Dis 40(5):373–3835. The, W.H.O.R.E.A.f.C.-T.W.G (2020) Association between admin-istration of systemic corticosteroids and mortality among critically illpatients with COVID-19: a meta-analysis. Jama 324(13):1330–13416. Piers R et al (2021) Letter to the editor: premorbid frailty is a betterprognostic indicator than age in oldest-old hospitalizedwith COVID-19. J Am Med Dir Assoc 22(3):514–5167. Janssen DJA et al (2020) COVID-19: guidance on palliative carefrom a European Respiratory Society international task force. EurRespir J 56(3)8. Curtis JR, Kross EK, Stapleton RD (2020) The importance of ad-dressing advance care planning and decisions about do-not-resuscitate orders during novel coronavirus 2019 (COVID-19).JAMA 323(18):1771–1772Publisher’s note Springer Nature remains neutral with regard to jurisdic-tional claims in published maps and institutional affiliations.2209Eur J Clin Microbiol Infect Dis (2021) 40:2207–2209

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Do-not-intubate status and COVID-19 mortality in patients admitted to Dutch non-ICU wards

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