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Why Should We Care About Sex Differences in Do Not Attempt Resuscitation Orders After In-Hospital Cardiac Arrest?

As an AHA Early Career Blogger and member of the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation (3CPR), I am pleased to have the opportunity to summarize the recently published paper in the Journal of the American Heart Association (JAHA), “Do Sex Differences Exist in the Establishment of ‘Do Not Attempt Resuscitation’ Orders and Survival in Patients Successfully Resuscitated From In-Hospital Cardiac Arrest?”1 This paper was published in February during American Heart Month in the JAHA Spotlight: Go Red for Women 2020 series in conjunction with AHA’s Go Red for Women initiative.

In summary, Perman et al.1 used the Get With The Guidelines®-Resuscitation registry to determine whether there are sex differences in the establishment of “do not attempt resuscitation” (DNAR) orders after resuscitation from in-hospital cardiac arrest and whether the differences in DNAR use lead to differences in survival. They examined 71820 patients across 571 hospitals who had return of spontaneous circulation (ROSC) after in-hospital cardiac arrest and examined the association between de novo DNAR orders (any time after ROSC, within 12 hours of ROSC, or within 72 hours of ROSC) and sex and the association between sex, DNAR orders, and survival. The 72-hour time point was selected since after this time is when patients who are comatose after cardiac arrest begin to have neurologic findings that indicate poor prognosis and AHA guidelines recommend that the determination of neurologic prognosis should be delayed until at least 72 hours after ROSC (or 72 hours after reaching normothermia if targeted temperature management is used).

Of the 71820 patients, 42.4% of the cohort were women and women were on average older (mean±SD: 65.5±15.8 vs. 64.6±15.1 years; P<0.0001), less frequently of non-Hispanic white race (61.7% vs. 67.5%, P<0.0001), more likely to have a non-shockable cardiac arrest rhythm such as pulseless electrical activity (PEA) or asystole (81.6% vs. 78.0%, P<0.0001), and more likely to have a noncardiac illness at the time of admission (47.2% vs. 41.1%, P<0.0001) while men had a higher incidence of cardiac premorbid conditions.

Of the total cohort, 44.1% had a de novo DNAR order placed after ROSC. Of the entire cohort, 45.0% of women and 43.5% of men had a DNAR order after ROSC (unadjusted RR: 1.16; 95% CI, 1.12-1.21; adjusted RR [ARR]: 1.15; 95% CI, 1.10-1.20). Women had a higher rate of DNAR status early after resuscitation. Of those who had any DNAR order during the hospitalization, 51.8% of women compared to 46.5% of men had a DNAR order placed <12 hours after ROSC and 75.9% of women compared to 70.9% of men had a DNAR order placed <72 hours after ROSC. When adjusting for the patients’ demographics and cardiac arrest characteristics, female sex was associated with a higher likelihood of early DNAR <12 hours after ROSC (ARR: 1.40; 95% CI, 1.30-1.52) and DNAR <72 hours after ROSC (ARR: 1.35; 95% CI, 1.26-1.45) among those who had a DNAR order any time after ROSC.

Interestingly, after adjusting for patient and arrest characteristics, female sex was mildly associated with lower rates of survival to hospital discharge (ARR: 0.98; 95% CI, 0.96-1.00; P=0.04) and there were no differences in survival rate between men and women after adjusting for DNAR status within 72 hours. However, early DNAR status made within 72 hours of ROSC (combining data from men and women) was associated with decreased survival rate compared to those without a DNAR order or a DNAR order placed ≥72 hours after arrest (RR: 0.15; 95% CI, 0.14-0.17; P<0.0001).

This study by Perman et al.1 is not the first study to note differences in rates of do not resuscitate (DNR)/DNAR orders between men and women. Nakagawa et al.2 showed that women with acute intracranial hemorrhage were more likely to receive early (<24 hours from presentation) DNR orders than men. In a study of patients who received emergency surgery, women were more likely to receive a DNR order but morbidity and mortality rates were similar between men and women3.

Unfortunately, the reasons for women to more likely receive earlier DNR/DNAR orders are unknown at this time. Perhaps these differences could be due to patient preferences (e.g. women having earlier end of life discussions with family/surrogate decision-makers), implicit provider biases (e.g. female cancer patients were found to be more likely to receive early DNR orders from female physicians4), surrogate decision-maker biases, sociocultural factors, religious factors, situational influences, etc. Although DNR/DNAR orders are not requests for withdrawal of life-sustaining therapy, the presence of DNR/DNAR orders has previously been associated with decreased aggressive interventions and decreased survival to discharge for patients with out-of-hospital cardiac arrest5. This suggests that health care providers should be vigilant of the tendency to be less aggressive with care for patients with DNR/DNAR orders and ensure that their management plans align with the expectations of surrogate decision-makers. More robust qualitative data are needed in order to understand these differences.

References:

  1. Perman SM, Beaty BL, Daugherty SL, Havranek EP, Haukoos JS, Juarez-Colunga E, Bradley SM, Fendler TJ, Chan PS, † AHAGWTGRI. Do sex differences exist in the establishment of “Do not attempt resuscitation” Orders and survival in patients successfully resuscitated from in-hospital cardiac arrest? J Am Heart Assoc. 2020;9:e014200
  2. Nakagawa K, Vento MA, Seto TB, Koenig MA, Asai SM, Chang CW, Hemphill JC. Sex differences in the use of early do-not-resuscitate orders after intracerebral hemorrhage. Stroke. 2013;44:3229-3231
  3. Eachempati SR, Hydo L, Shou J, Barie PS. Sex differences in creation of do-not-resuscitate orders for critically ill elderly patients following emergency surgery. J Trauma. 2006;60:193-197; discussion 197-198
  4. Crosby MA, Cheng L, DeJesus AY, Travis EL, Rodriguez MA. Provider and patient gender influence on timing of do-not-resuscitate orders in hospitalized patients with cancer. J Palliat Med. 2016;19:728-733
  5. Richardson DK, Zive D, Daya M, Newgard CD. The impact of early do not resuscitate (dnr) orders on patient care and outcomes following resuscitation from out of hospital cardiac arrest. Resuscitation. 2013;84:483-487

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Learning on the Go – Some Podcast Recommendations

As researchers, clinicians, and/or trainees, there never seems to be enough time in the day to get all the stuff done that we want to get done. There seems to always be more papers that we want or should read. One of my favorite ways to try to stay up to date with the latest research publications is listening to podcasts. I enjoy listening to podcasts while commuting and doing chores, and sometimes while working in the lab when no one else is around. Depends on my mood whether I can listen to a podcast while exercising or would prefer to listen to more energetic music.

Below is a list of some of my favorite cardiology podcasts. This is not a comprehensive list and I am not affiliated with any of these podcasts. I also am not endorsing any of the content discussed in the below podcasts. This list is also biased towards those podcasts that are easily accessible via smartphone podcast/listening applications and do not require downloading individual episodes from specific websites. These podcasts are not listed in any particular order.

  • Circulation on the Run: Summarizes the articles published in a specific issue of Circulation and has a more in-depth discussion of a featured article.
  • Discover CircRes: Summarizes the articles published in a specific issue of Circulation Research and also has a more in-depth discussion of a featured article often with the article’s corresponding author as well as the trainee involved in the article.
  • The Bob Harrington Show: Interviews and discussions of various topics in cardiology and the practice of medicine.
  • This Week in Cardiology: Dr. John Mandrola summarizes and provides his insight on some of the top news in cardiology for the week.
  • JACC Podcast: Dr. Valentin Fuster, editor-in-chief of the Journal of American College of College (JACC) provides an overview and summary of the articles published in a specific issue of JACC.
  • Eagle’s Eye View Your Weekly CV Update from ACC.org: A weekly cardiovascular update from Dr. Kim Eagle, editor-in-chief of ACC.org.
  • ACCEL Lite Features ACCEL Interview on Exciting CV Research: Interviews and summaries of some of cardiology’s most interesting research topics, hosted by Dr. Spencer King III.
  • Heart: Summaries of original research, editorials, and reviews from the BMJ’s Heart
  • Heart Sounds with Shelley Wood: Discusses some of the top stories in cardiology covered by the TCTMD reporters.
  • CardioNerds: This is a podcast that I just started listening to. It discusses high yield cardiovascular topics in a case discussion format.
  • AP Cardiology, ACC CardiaCast, Cardiac Consult A Cleveland Clinic Podcast for Healthcare Professionals: Three different podcasts that provide summaries of various cardiology topics.
  • JAMA Editors’ Summary, JAMA Clinical Reviews, JAMA Medical News Interviews and Summaries: Three different podcasts which provide summaries of various medical topics.
  • Annals of Internal Medicine Podcast: Highlights and interviews from a specific issue of Annals of Internal Medicine. The American College of Physicians has another podcast, Annals On Call Podcast, which features Dr. Bob Centor discussing influential articles that are published in Annals of Internal Medicine. I have not yet started listening to Annals on Call, but hope to do so in the near future.
  • ED ECMO: Discusses resuscitative extra-corporeal membrane oxygenation (ECMO) and extra-corporeal life support (ELS). At the University of Minnesota, cardiologists manage veno-arterial ECMO (VA-ECMO). More to come about this during an upcoming blog!

I am always open to hearing suggestions for new podcasts related to science/medicine or other topics!

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

 

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What Are Your Thoughts on Work-Life Balance/Imbalance in Science and Medicine?

My blog post this month is meant to be a starting point for discussion. There are a plethora of articles and blog posts on work-life balance/imbalance in medicine and science (and many other professions). Some articles and blog posts even discuss that it is not possible to have work-life balance in medicine/science/academia1-3. As the winter holiday season comes to an end and a new year and decade starts, I find myself reassessing my personal and professional goals and resolutions for this upcoming year and decade. On my list is “continuing to work on work-life balance.” My blog is meant to stimulate discussion and solicit advice from those of you in science and medicine on potential tips to improve work-life balance. Figuring out how to balance the personal and professional aspects of our lives throughout a long and arduous career can be a formidable process.

Some people have voiced concerns about the recommendations often told to trainees and early career physicians/scientists to maintain work-life balance and wellness in order to prevent burnout: get adequate sleep, eat well, exercise, meditate, pet dogs, wake up earlier to plan your day, travel, read nonmedical/nonscience books, continue your hobbies, find good mentors, and spend time with family and friends all while providing good clinical care and/or doing good research. How are there enough hours in a day to do all of this?

An article in The Atlantic published last year entitled “Give Up on Work-Life Balance”4 discusses a recommendation from Brad Stulberg, author of The Passion Paradox, of not thinking of work-life balance as dividing hours within a day for personal and work activities. Alternatively, consider balance in terms of “seasons.” For example, one “season” could be a few years where the majority of the time is focused on one’s training/career and another “season”, possibly during a time when one has young children, where focus is on spending time with family. One of my mentors who has young children says that when he goes home, he prioritizes spending time with family and tries not to do any work until he and his wife go to bed. Some people have noted that they dislike the term work-life balance since it implies that there is a scale where one side is competing against the other. Instead, “integrating” work and personal lives is encouraged. Unfortunately, careers in science and/or medicine do not always allow for easy integration of work and personal lives, but system changes can occur to allow for better integration of work and personal life. For example, I applaud the efforts of one of my co-AHA early career bloggers, Dr. Nosheen Reza (@noshreza), in assisting with establishing a culture and creating tangible changes to support breastfeeding cardiology fellows5. Another AHA early career blogger, Dr. Renee Bullock-Palmer (@RBP0612) wrote a blog post last year discussing tips for integrating motherhood and a career as a female cardiologist (https://earlycareervoice.professional.heart.org/balancing-versus-integration-of-motherhood-and-your-career-as-a-female-cardiologist/).

Many established researchers and clinicians have recently told me that they regret not spending more time with their families. This same sentiment has been echoed by many clinicians/researchers on Twitter over the holiday season. While it is not always possible to spend every holiday with loved ones, especially while in training, allotting some protected time to spend with loved ones is important for maintaining wellness.

Establishing work-life balance is a constant evolving process dependent on the stage of our careers and personal lives and is a very individualized process. As mentioned before, I hope that we can have a further discussion on work-life balance and that you will share some tips on ways to improve work-life balance. I wish all of you a happy, healthy, and productive new year!

 

  1. Lazzari, Elisa. To be a top performer you need to be happy – something academics tend to forget. Naturejobs Blog. 13 Jun 2016. http://blogs.nature.com/naturejobs/2016/06/13/can-scientists-really-have-worklife-balance/.
  2. Powell, K. Young, talented and fed-up: scientists tell their stories. Nature538, 446–449 (2016).
  3. Is Work-Life Balance for Physicians a Unicorn? com. 3 Jan 2018. https://www.kevinmd.com/blog/2018/01/work-life-balance-physicians-unicorn.html
  4. Khazan, Olga. Give Up on Work-Life Balance. The Atlantic. Atlantic Media Company. 30 May 2019. https://www.theatlantic.com/health/archive/2019/05/work-life-balance/590662/.
  5. Kay J, Reza N and Silvestry FE. Establishing and Expecting a Culture of Support for Breastfeeding Cardiology Fellows. JACC: Case Reports. 2019;1:680-683.

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.

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3CPR Shark Tank Competition at AHA19: “Fish are Friends, Not Food!”

Some of the highlights of AHA19 for me include seeing the support that the AHA and many established cardiovascular leaders who are part of the AHA give to early career investigators and to see some of the amazing work completed by trainees. Specifically in the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation (3CPR), there were many opportunities for trainees to showcase their work at AHA19 including at poster sessions, moderated poster sessions, the Cournand and Comroe Early Career Investigator Award Competition, Kenneth D. Bloch Memorial Lecture in Vascular Biology, and one of my favorite sessions that I watched this year, the 3CPR Shark Tank Competition.

To follow my previous blog post on mentorship, this post will discuss the 3CPR Shark Tank Competition, an opportunity for trainees to receive mentorship from an established leader in cardiovascular medicine at another institution.

shark tankThe TV show, Shark Tank, is a reality TV show where entrepreneurs pitch business ideas to a panel of investors known as “sharks” who then decide whether to invest in the entrepreneurs’ businesses. Similarly, in the 3CPR Shark Tank Competition, early career candidates present their proposed research project to the “sharks” who are leaders in cardiovascular medicine. Winners receive mentorship from a mentor that is not at their home institution. Specifically, the winners receive a sponsored visit to the mentor’s institution to present research or attendance at a future conference with the mentor, the mentor will review the mentee’s future grant aims page, and there are three phone calls over a year between the mentor and mentee to review data and progress towards establishing the mentee’s research program. The AHA and “sharks” contribute money to defer the costs of travel for the mentee. The goals of the Shark Tank Competition are to highlight some of the most promising junior investigators and leaders in 3CPR, promote new ways of mentorship, and show early career members what some of the important issues when presenting research ideas are from a senior perspective.

Dr. Kimberly Dunham-Snary, a postdoctoral fellow in Dr. Stephen Archer’s lab at Queen’s University and winner of the 2018 Shark Tank Competition spoke very highly on the mentoring that she received after winning the 3CPR Shark Tank Competition: “Dr. Rabinovitch organized a mock faculty interview for my visit to Stanford and [I] met with numerous faculty one-on-one. I received advice about everything from chalk talk to grantsmanship to mentoring strategies. This definitely helped me prepare for my current faculty interviews. Thanks so much to Dr. Rabinovitch and to 3CPR for proving me with this training opportunity!”

Selected candidates to present in the 3CPR Shark Tank Competition had a top scoring abstract submitted to AHA Scientific Sessions or the Resuscitation Sciences Symposium (ReSS) and must be an early career investigator who is at the end of his/her postdoctoral fellowship and is planning on transitioning towards independence. Ideal candidates are looking to submit a K or AHA Career Development grant application in the next year. Each candidate has four minutes to present their proposed research program/project and the candidates can only have a single slide to support their presentation. The “sharks” then have seven minutes to clarify, question, critique, and vie for the affections of the candidates. Winners are selected by the “sharks” and audience scoring, each accounting for 50% of the final score.

This year was the second annual 3CPR Shark Tank Competition. The competition began with the “sharks” reciting the Shark Pledge in the movie, Finding Nemo (“I am a nice shark, not a mindless eating machine. […] Fish are friends, not food!”)1. This year’s “sharks” were Dr. Mark Gladwin from University of Pittsburgh; Dr. Jane Leopold from Brigham and Women’s Hospital; Dr. Robert Neumar from University of Michigan; Dr. Werner Seeger at the Max-Planck Institute for Heart and Lung Research and Universities of Giessen and Marburg in Germany; Dr. Marc Semigran, chief medical officer of MyoKardia; and Dr. Terry Vanden Hoek at the University of Illinois in Chicago. Winners of this year’s Shark Tank Competition were Dr. Alexis Steinberg, Neuro-Critical Care Fellow at the University of Pittsburg; Dr. Taijya Satoh, postdoctoral fellowship in Dr. Gladwin’s laboratory at University of Pittsburg; and Dr. Rajat Kalra, Advanced Imaging Fellow at the University of Minnesota.

Not only is the 3CPR Shark Tank Competition a great opportunity for trainees who are in 3CPR to participate in, it was very entertaining to watch. I think that since the competition was at night around dinner time, as the evening progressed, the “sharks” may have gotten a little more irritable and had to be reminded that minnows are friends. I encourage FITs in 3CPR to consider participating in the 3CPR Shark Tank Competition in the future and for all trainees in 3CPR and any other council to consider watching this entertaining competition in the future!

 

References:

  1. Finding Nemo. Directed by Andrew Stanton and Lee Unkrich, Walt Disney Pictures, 30 May 2003.

 

Acknowledgments:

Thank you to Dr. Kurt Prins, one of the organizers of the 3CPR Shark Tank Competition, for providing me with information about the Shark Tank Competition and to Dr. Kimberly Dunham-Snary for allowing me to share her feedback on her experience with the Shark Tank Competition.

 

 

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.

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Benefits of joining an early career investigator’s lab

In addition to learning about some fantastic science and research, one of the major benefits of attending American Heart Association’s Scientific Sessions (or any other national meeting) as a fellow-in-training is the networking opportunities. Trainees can take advantage of the opportunity to interact with principal investigators and/or members of labs that they may be interested in joining in the future.

While there are many benefits to joining an established lab, I strongly encourage trainees to consider meeting with and possibly consider joining a new/early career investigator’s lab. There are several benefits to joining an early career investigator’s lab.

I recently joined an early career investigator’s lab for my postdoctoral fellowship. I am a Cardiology physician-scientist trainee. I completed a Medical Scientist (MD/PhD) Program and then joined a Physician Scientist Training Program in Internal Medicine. I completed my Internal Medicine residency and then started my Cardiology fellowship. I spent a long time finding a lab to do my research postdoctoral fellowship. Fortunately, I had the opportunity to join Dr. Kurt Prins lab. Dr. Prins is a Cardiology physician-scientist who studies the mechanisms of right ventricular dysfunction in pulmonary hypertension and is an early career investigator.

Below are some of the benefits of joining an early career investigator’s lab:

  1. Mentorship: As my mentor’s first and only postdoctoral trainee so far, I have received a lot of individualized mentorship. His office door has always been open and I talk to him almost every day about science, career advice, and/or our personal lives. Due to Kurt’s approachability and availability, I feel that I may have been able to be more productive in the lab, partly due to the ease of working with him to troubleshoot experiments.
  2. Establishing the groundwork for many projects: In smaller labs, the lab members are often involved in multiple/all projects. It is exciting to be able to lay the groundwork for multiple projects that the lab may be involved in for years to come or may be the foundation of my lab in the future. Being involved in multiple projects may also lead to multiple publications.
  3. Learning how to start and set up a lab: I joined Kurt’s lab a year after he started his lab. Watching the process of starting and setting up a new lab is invaluable. As a trainee who is interested in starting her own lab in the future, being closely involved in writing/reviewing animal protocols, reviewing grant applications, and even organizing the freezer racks will help with tackling the inevitable steep learning curve of being an independent investigator. Sometimes in a more established lab, one may not receive the experience of learning all of the processes involved in setting up and running a lab.
  4. Mentor can empathize on the potential struggles of being an early stage investigator: Early career principal investigators can often empathize with trainees on the challenges of obtaining grant funding and publishing papers during the current research climate along with possible other scientific/personal challenges. Early stage investigator can provide trainees with relevant career advice that are applicable in today’s scientific environment.
  5. Doing experiments with principal investigator: At this time, my mentor spends a lot of time in the lab doing experiments alongside the other lab members, which makes the lab environment a lot of fun! Kurt and I have developed a lot of inside jokes between us because of the amount of time we spend together!

While there are many benefits to joining an early career investigator’s lab, there are also some potential difficulties that can easily be overcome. For further career development, it may also be valuable to have a senior mentor. As you have probably heard before, ultimately deciding which lab to join for your graduate or postdoctoral training is like finding a spouse – you have to find a good match. For those who are interested, there was an article published in Nature about the potential benefits of joining a new lab (1). For those of you who want to discuss more about potentially joining an early career investigator’s lab, please feel free to reach out to me. For those of you who joined an early career investigator’s lab, I would also be interested in hearing about your experiences.

 

References

  1. Woolston C. Why a new lab can be a valuable destination for postdocs and graduate students. Nature. 2018;558:333-335

 

 

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.