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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
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
Corresponding
E-mail address:

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.

Type
Original Articles
Copyright
Copyright © Cambridge University Press 2008

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