Do-not-resuscitate status and regional analgesia utilization for fracture pain: a comfort paradox?

Background Do-not-resuscitate orders are intended to prioritize patient comfort, but do-not-resuscitate patients may receive fewer procedural interventions. Regional analgesia is recommended for rib and hip fractures and may provide superior pain control to systemic analgesics. However, utilization remains low. Whether do-not-resuscitate status is associated with the utilization of comfort-enhancing regional analgesia has not been studied. Methods This was a cross-sectional study using the National Inpatient Sample of adult (≥18 years) hospitalizations for rib and hip fractures identified using International Classification of Diseases, 10th Revision codes from January 1, 2016, through December 31, 2022. The primary exposure was do-not-resuscitate status. The primary outcome was receipt of regional analgesia. Results 298,343 rib fracture and 462,796 hip fracture hospitalizations met inclusion criteria, of which 8,568 (2.9%) and 13,730 (3.0%) received regional analgesia, respectively. Do-not-resuscitate status was present in 31,882 (10.7%) of rib fracture and 77,255 (16.7%) hip fracture hospitalizations. In adjusted analyses, do-not-resuscitate status was associated with lower odds of regional analgesia for rib fractures (OR 0.76; 95% CI 0.6 9 to 0.8 3 ), but not hip fractures (OR 1.00; 95% CI 0.94 to 1.06). In frailty-stratified analyses, the association between do-not-resuscitate status and lower rates of regional analgesia utilization was strongest among the least frail rib fracture hospitalizations (OR 0.34; 95% CI 0.25 to 0.48). Conclusions Do-not-resuscitate status is associated with lower regional analgesia utilization for rib fractures but not hip fractures. Prospective studies are needed to confirm these findings.