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DNR order in SARS-CoV-2 patients: preliminary guidelines validation and quality of palliative care in a single Swiss COVID-19 Center.

Background: The worldwide pandemic situation forced many hospitals to improve COVID-19 management. In this scenario, the Swiss Academy of Medical Sciences (SAMW/ASSM) organized guidelines based on expert opinion to identify Do-Not-Resuscitate (DNR) patients, which often need palliative care (PC) due to a large symptoms burden. In our specialized COVID-19 Center, we investigated characteristics and mortality of DNR patients according to SAMW/ASSM guidelines, comparing to non-DNR patients. Methods: Pilot retrospective validation study, evaluating consecutive COVID-19 patients admitted to Internal Medicine Department. A sub-analysis of the deceased patients care was performed, using both Richmond Agitation-Sedation Scale-Palliative care (RASS-PAL) for sedation and agitation (+4/-5) and modified Borg Scale for dyspnea (1-10). Primary outcome was a 30-days survival of DNR patients comparing to non-DNR patients. Secondary outcomes reported quality of PC, especially on dyspnea and restlessness. Results: From March 16 to April 1 2020, 213 consecutive patients were triaged; of 40 DNR patients 25 (64%) were males with a mean age of 79.9 years. At 30-days follow-up, 9 (22.5%) of DNR patients died; 4 patients (2.2%) died in the control group. The higher mortality rate in DNR group was further confirmed by Log-Rank Mantel-Cox (23.104, p < 0.0001). PC was applied using oxygen (100%), opioids (100%) and sedatives (89%); the mean RASS-PAL improved from 2.2 to -1.8 (p < 0.0001) and Borg scale improved from 5.7 to 4.7 (p = 0.581). Conclusion: The SAMW/ASSM guidelines identified patients at higher risk of short-term death. In the end-of-life management, an early access to PC becomes crucial, both improving patients' end-of-life treatment and reducing psychological families' post-traumatic disorders.