Letter to “Early do-not-attempt resuscitation orders and neurological outcomes in older out-of-hospital cardiac arrest patient: A multicenter observational study”

We enjoyed reading the article by Kohri et al., titled “Early do-not-attempt resuscitation orders and neurological outcomes in older out-of-hospital cardiac arrest patients: A multicenter observational study” and would like to offer additional commentary on the article.¹ We hope these perspectives may provide insight into areas that may require further research and improvement.

Kohri et al. reported on the association between early DNR orders and neurological outcomes in OHCA patients, highlighting any possible trends between early DNR orders and OHCA patients. They found that those with a DNR order placed received less therapeutic care intervention and had worse neurological outcomes after the same time period, compared to non-DNR patient counterparts. The paper calls for the reconsideration of the implementation of DNR shortly after cardiac arrest in acute care settings.

Kohri et al. had studied the DNR orders and their associated outcomes; however, it lacks the comprehensive assessment of the patient's symptoms leading to the DNR orders, which presents several limitations in the observational study. As a result of this, the conclusion may be misleading as the DNR decision-making may have been impacted by other factors, such as pain management.²

Although the article has a limited level of balancing and confounding through elements such as propensity score analysis, it does not account for subjectivity and biases on the personal level. The clinical judgment or personal biases may vary from individual to individual, and different institutions and hospitals may have their own policies and clinical expertise, resulting in a reduction in the robustness of the conclusion.³

Lastly, the methodology used in the article is quite simplistic and does not capture the overwhelmingly complex reality of healthcare, in which there are a number of different variables that could affect it, such as religion, belief, or socio-economic factors of the family outside the clinical field.⁴

Ultimately, this paper presents a timely and relevant investigation into the correlation between DNR decisions and the neurological outcomes of OHCA patients. By addressing these issues, we can help strengthen the conclusions of essential studies used to improve healthcare globally. We applaud the authors for not only emphasizing the importance of the stress of issuing DNR orders early into care inside an acute care setting. We look forward to reading about future studies that provide insight into these factors.

No funding was received for this study/paper.

The authors declare no conflicts of interest.

Approval of the research protocol: N/A.

Informed consent: N/A.

Registry and the registration no. of the study/trial: N/A.

Animal studies: N/A.