DNAR Differences Do Not Explain Racial, Ethnic Disparities in Survival After Cardiac Arrest

Black and Hispanic patients experience lower survival rates after in-hospital cardiac arrest than White patients, but new research suggests that early do-not-attempt-resuscitation (DNAR) orders are not driving these disparities.¹ In a study of adults successfully resuscitated after in-hospital cardiac arrest, investigators found that American Indian or Alaska Native, Black, and Hispanic patients were significantly less likely than White patients to have DNAR orders placed within the first 12 or 72 hours following return of spontaneous circulation.

Importantly, when early DNAR orders were in place, survival to hospital discharge was similar across racial and ethnic groups, challenging assumptions about the role of resuscitation preferences in unequal cardiac arrest outcomes.

This prospective cohort study is published in JAMA Network Open.

“Among patients with early DNAR orders placed, there was no significant survival difference by race or ethnicity,” wrote the researchers of the study. “Therefore, it is unlikely that the placement of early DNAR orders in isolation drives a disparity in survival to hospital discharge among variable racial and ethnic groups. One might surmise that if White patients have a higher incidence of DNAR, they should equally experience less survival, yet no survival difference was measured.”

Black and Hispanic patients consistently experience lower survival rates after cardiac arrest compared with White patients, even when they initially reach the hospital.² Studies show that Black and Hispanic individuals are more likely to be treated at hospitals with lower overall quality measures and poorer patient outcomes, which contributes to worse survival to discharge and less favorable neurological recovery than that seen in White patients.

The study analyzed data from the American Heart Association’s Get With the Guidelines–Resuscitation registry, which captures standardized information on in-hospital cardiac arrest events from more than 350 US hospitals.¹ Adult patients aged 18 years or older who experienced an index in-hospital cardiac arrest between 2018 and 2023 and achieved return of spontaneous circulation while admitted to a hospital unit were included.

Race and ethnicity were categorized as American Indian or Alaska Native, Asian, Black, Hispanic, or White. The primary outcomes were the placement of early DNAR orders within 12 hours and within 72 hours of resuscitation, as well as survival to hospital discharge among patients with early DNAR orders. Additionally, the researchers assessed associations between race and ethnicity and DNAR order placement, adjusting for patient demographics, clinical characteristics, and hospital factors. Data were analyzed from September 26, 2024, through February 8, 2025.

Among 93,843 adults who achieved return of spontaneous circulation after in-hospital cardiac arrest between 2018 and 2023, 60.7% were White, 22.7% Black, 7.5% Hispanic, 2.5% American Indian or Alaska Native, and 0.8% Asian.

Overall, early DNAR orders were more common among White patients, with 25.3% having a DNAR order within 12 hours and 37.4% within 72 hours of resuscitation, compared with 21.3% and 33.4% of American Indian or Alaska Native patients, 21.4% and 32.7% of Black patients, and 22.2% and 33.2% of Hispanic patients, respectively.

In adjusted analyses, American Indian or Alaska Native (OR, 0.78; 95% CI, 0.67-0.91), Black (OR, 0.74; 95% CI, 0.69-0.79), and Hispanic (OR, 0.90; 95% CI, 0.82-0.99) patients were significantly less likely than White patients to have DNAR orders entered within 12 hours; similar patterns were observed within 72 hours.

Additionally, survival to hospital discharge occurred in 39.0% of White patients, compared with 34.2% of American Indian or Alaska Native, 33.7% of Black, and 34.5% of Hispanic patients. However, among patients with an early DNAR order placed within 72 hours, adjusted analyses showed no significant differences in survival to discharge by race or ethnicity.

However, the study had several limitations, including missing race and ethnicity data for some patients, as well as the data set’s inability to capture how early DNAR decisions are made. Additionally, although the registry includes over 350 US hospitals, it may not fully represent all patients with in-hospital cardiac arrest, limiting generalizability.

Despite these limitations, the researchers believe the study suggests that differences in early DNAR placement do not explain racial and ethnic disparities in overall survival, highlighting the need to explore other clinical and systemic factors contributing to unequal outcomes after in-hospital cardiac arrest.

“In this cohort study, American Indian or Alaska Native, Black, and Hispanic patients were less likely to have early DNAR orders entered than White patients, but there were no differences in survival by race among patients with early DNAR orders placed,” wrote the researchers. “More research is needed to understand how families and clinicians make decisions about DNAR orders after resuscitation from in-hospital cardiac arrest.”

References

1. Raymond-King C, Wan X, Cook R, et al. Race and ethnicity and early do not attempt to resuscitation orders after in-hospital cardiac arrest. JAMA Netw Open. 2026;9(1):e2553504. doi:10.1001/jamanetworkopen. 2025.53504

2. Black, Hispanic cardiac arrest survivors often treated at hospitals with lower quality measures. American Heart Association. November 6, 2023. Accessed January 12, 2026. https://newsroom.heart.org/news/black-hispanic-cardiac-arrest-survivors-often-treated-at-hospitals-with-lower-quality-measures