Hostname: page-component-6bb9c88b65-2jdt9 Total loading time: 0 Render date: 2025-07-19T13:16:28.162Z Has data issue: false hasContentIssue false
  • English
  • Français

How do-not-resuscitate orders are utilized in cancer patients: Timing relative to death and communication-training implications

Published online by Cambridge University Press:  13 November 2008

Tomer T. Levin ,
Yuelin Li ,
Joseph S. Weiner ,
Frank Lewis ,
Abraham Bartell ,
Jessica Piercy  and
David W. Kissane
Tomer T. Levin*
Affiliation:
Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, New York Weill Cornell College of Medicine, New York, New York
Yuelin Li
Affiliation:
Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, New York Weill Cornell College of Medicine, New York, New York
Joseph S. Weiner
Affiliation:
Departments of Psychiatry and Medicine, North Shore University Hospital, Manhasset, New York Albert Einstein College of Medicine, Bronx, New York
Frank Lewis
Affiliation:
Dataline, Memorial Sloan-Kettering Cancer Center, New York, New York
Abraham Bartell
Affiliation:
Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, New York Weill Cornell College of Medicine, New York, New York
Jessica Piercy
Affiliation:
Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, New York
David W. Kissane
Affiliation:
Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, New York Weill Cornell College of Medicine, New York, New York
*
Address correspondence and reprint requests to: Tomer Levin, Memorial Sloan-Kettering Cancer Center, 641 Lexington Ave, New York, NY 10022. E-mail: levint@mskcc.org
Get access Rights & Permissions [Opens in a new window]

Abstract

Objectives:

End-of-life communication is crucial because most U.S. hospitals implement cardiopulmonary resuscitation (CPR) in the absence of do-not-resuscitate directives (DNRs). Despite this, there is little DNR utilization data to guide the design of communication-training programs. The objective of this study was to determine DNR utilization patterns and whether their use is increasing.

Methods:

A retrospective database analysis (2000–2005) of DNR data for 206,437 patients, the entire patient population at Memorial Sloan-Kettering Cancer Center (MSKCC), was performed.

Results:

The hospital recorded, on average, 4,167 deaths/year. In 2005, 86% of inpatient deaths had a DNR, a 3% increase since 2000 (p < .01). For patients who died outside the institution (e.g., hospice), 52% had a DNR, a 24% increase over 6 years (p < .00001). Adult inpatients signed 53% of DNRs but 34% were signed by surrogates. The median time between signing and death was 0 days, that is, the day of death. Only 5.5% of inpatient deaths had previously signed an outpatient DNR. Here, the median time between signing and death was 30 days.

Significance of results:

Although DNR directives are commonly utilized and their use has increased significantly over the past 6 years, most cancer patients/surrogates sign the directives on the day of death. The proximity between signing and death may be a marker of delayed end-of-life palliative care and suboptimal doctor–patient communication. These data underscore the importance of communication-training research tailored to improve end-of-life decision making.

Keywords

Do-not-resuscitate ordersCommunication trainingDeath and dyingPalliative care

Information

Type
Original Articles
Information
Palliative & Supportive Care , Volume 6 , Issue 4 , December 2008 , pp. 341 - 348
Copyright
Copyright © Cambridge University Press 2008

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

References

REFERENCES

Azoulay, E., Pochard, F., Kentish-Barnes, N., et al. (2005). Risk of post-traumatic stress symptoms in family members of intensive care unit patients. American Jounal of Respiratory and Critical Care Medicine, 171, 987–994.CrossRefGoogle ScholarPubMed
Barry, L.C., Kasl, S.V. & Prigerson, H.G. (2002). Psychiatric disorders among bereaved persons: the role of perceived circumstances of death and preparedness for death. The American Journal of Geriatric Psychiatry, 10, 447–457.CrossRefGoogle ScholarPubMed
Bradshaw, G.G., Hinds, P.S., Lensing, S., et al. (2005). Cancer-related deaths in childern and adolescents. Journal of Palliative Medicine, 8, 86–95.CrossRefGoogle Scholar
Braun, K.L., Onaka, A.T. & Horiuchi, B.Y. (2001). Advance directive completion rates and end-of-life preferences in Hawaii. Journal of the American Geriatrics Society, 49, 1708–1713.CrossRefGoogle ScholarPubMed
Christakis, N.A. (1999). Death Foretold. Prophesy and Prognosis in Medical Care. Chicago: University of Chicago Press.Google Scholar
Creation and Use of Proxies in Residential Health Care and Mental Hygiene Facilities. N.Y. Public §2991(1993).Google Scholar
Fins, J.J., Miller, F.G., Acres, C.A., et al. (1999). End-of-life decision-making in the hospital: current practice and future prospects. Journal of Pain and Symptom Management, 17, 6–15.CrossRefGoogle ScholarPubMed
Fleiss, J.L. (1981). Statistical Methods for Rates and Proportions. New York: Wiley.Google Scholar
Haidet, P., Hamel, M.B., Davis, R.B., et al. (1998). Outcomes, preferences for resuscitation, and physician-patient communication among patients with metastatic colorectal cancer. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. The American Journal of Medicine, 105, 222–229.CrossRefGoogle ScholarPubMed
Hanson, L.C. & Rodgman, E. (1996). The use of living wills at the end of life. A national study. Archives of Internal Medicine, 156, 1018–1022.CrossRefGoogle ScholarPubMed
Kahana, B., Dan, A., Kahana, E., et al. (2004). The personal and social context of planning for end-of-life care. Journal of the American Geriatrics Society, 52, 1163–1167.CrossRefGoogle ScholarPubMed
Lunney, J.R., Lynn, J., Foley, D.J., et al. (2003). Patterns of functional decline at the end of life. JAMA, 289, 2387–2392.CrossRefGoogle ScholarPubMed
National Consenus Project for Quality Palliative Care (2004). Clinical practice guidelines for quality palliative care. New York: National Consensus Project for Quality Palliative Care.Google Scholar
Oh, D.Y., Kim, J.H., Kim, D.W., et al. (2006). CPR or DNR? End-of-life decision in Korean cancer patients: A single center's experience. Supportive Care in Cancer, 14, 103–108.CrossRefGoogle ScholarPubMed
Patient Self-determination Act. 42 U.S.C. §1395cc(f) (1992).Google Scholar
R-Development-Core-Team. (2004). R: A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing.Google Scholar
Solloway, M., LaFrance, S., Bakitas, M., et al. (2005). A chart review of seven hundred eighty-two deaths in hospitals, nursing homes, and hospice/home care. Journal of Palliative Medicine, 8, 789–796.CrossRefGoogle ScholarPubMed
Weiner, J.S. & Cole, S.A. (2004a). A Care: A communication training program for shared decision making along a life-limiting illness. Palliative & Supportive Care, 2, 231.CrossRefGoogle Scholar
Weiner, J.S. & Cole, S.A. (2004b). Three principles to improve clinician communication for advance care planning: overcoming emotional, cognitive, and skill barriers. Journal of Palliative medicine, 7, 817.CrossRefGoogle ScholarPubMed
Weiner, J.S. & Roth, J. (2006). Avoiding Iatrogenic harm to patient and family while discussing goals of care near the end of life. Journal of Palliative Medicine, 9, 451–463.CrossRefGoogle ScholarPubMed
Wolfe, J., Grier, H.E., Klar, N., et al. (2000). Symptoms and suffering at the end of life in childern with cancer. The New England Journal of Medicine, 342, 326–333.CrossRefGoogle Scholar