Characteristics and outcomes of non-critically ill extremely elderly patients with do-not-attempt-resuscitation orders admitted to a university hospital in Japan: a retrospective cohort study

BACKGROUND: Do-not-attempt-resuscitation (DNAR) orders are commonly issued for patients of advanced age in the setting of severe illness with an anticipated risk of mortality. However, DNAR orders are also observed among extremely elderly patients who are not critically ill at admission. The characteristics and outcomes of such patients remain poorly understood. This study aimed to characterize these patients and to examine the association between DNAR status and discharge outcomes. METHODS: We retrospectively analyzed non-critically ill (National Early Warning Score [NEWS] of 4 or less) hospitalized patients aged 85 years or older admitted to a university hospital in Japan between 2022 and 2024 using electronic medical record data. Patients with and without DNAR orders were compared in terms of age, sex, activities of daily living (ADL), disease severity (NEWS), primary diagnoses, comorbidities, laboratory data, and discharge outcomes using univariable analyses. A Fine‒Gray competing-risk model examined the association between DNAR orders and transfer to post-acute care facilities, with discharge to home and death as competing events. RESULTS: Among the 1,230 eligible patients, 72 (5.9%) had DNAR orders. Patients with DNAR orders were older, had lower ADL, and had higher NEWS at admission. Primary diagnoses and comorbidities showed no consistent pattern between the two groups. Laboratory findings at admission showed lower hemoglobin and albumin levels and higher C-reactive protein levels in the DNAR group. Patients with DNAR orders were less likely to be discharged home, more likely to be transferred to post-acute care facilities or die in hospital, and had longer hospital stays. DNAR orders were associated with a higher probability of transfer to post-acute facilities (subdistribution hazard ratio 2.11; 95% confidence interval 1.21-3.69). CONCLUSIONS: Among non-critically ill extremely elderly hospitalized patients, those with DNAR orders were older, had lower ADL, and had higher disease severity. The presence of DNAR orders was associated with unfavorable discharge outcomes independent of age, ADL, and disease severity.