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

  • Tomer T. Levin (a1) (a2), Yuelin Li (a1) (a2), Joseph S. Weiner (a3) (a4), Frank Lewis (a5), Abraham Bartell (a1) (a2), Jessica Piercy (a1) and David W. Kissane (a1) (a2)...



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.


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.


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.


Corresponding author

Address correspondence and reprint requests to: Tomer Levin, Memorial Sloan-Kettering Cancer Center, 641 Lexington Ave, New York, NY 10022. E-mail:


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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, 987994.
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, 447457.
Bradshaw, G.G., Hinds, P.S., Lensing, S., et al. (2005). Cancer-related deaths in childern and adolescents. Journal of Palliative Medicine, 8, 8695.
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, 17081713.
Christakis, N.A. (1999). Death Foretold. Prophesy and Prognosis in Medical Care. Chicago: University of Chicago Press.
Creation and Use of Proxies in Residential Health Care and Mental Hygiene Facilities. N.Y. Public §2991(1993).
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, 615.
Fleiss, J.L. (1981). Statistical Methods for Rates and Proportions. New York: Wiley.
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, 222229.
Hanson, L.C. & Rodgman, E. (1996). The use of living wills at the end of life. A national study. Archives of Internal Medicine, 156, 10181022.
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, 11631167.
Lunney, J.R., Lynn, J., Foley, D.J., et al. (2003). Patterns of functional decline at the end of life. JAMA, 289, 23872392.
National Consenus Project for Quality Palliative Care (2004). Clinical practice guidelines for quality palliative care. New York: National Consensus Project for Quality Palliative Care.
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, 103108.
Patient Self-determination Act. 42 U.S.C. §1395cc(f) (1992).
R-Development-Core-Team. (2004). R: A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing.
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, 789796.
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.
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.
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, 451463.
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, 326333.


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

  • Tomer T. Levin (a1) (a2), Yuelin Li (a1) (a2), Joseph S. Weiner (a3) (a4), Frank Lewis (a5), Abraham Bartell (a1) (a2), Jessica Piercy (a1) and David W. Kissane (a1) (a2)...


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