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

Tomer T. Levin, Yuelin Li, Joseph S. Weiner, Frank B.S. Lewis, Abraham M.D. Bartell, Jessica B.A. Piercy, David W. Kissane

Research output: Contribution to journalArticleResearchpeer-review

58 Citations (Scopus)

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.

Original languageEnglish
Pages (from-to)341-348
Number of pages8
JournalPalliative and Supportive Care
Volume6
Issue number4
DOIs
Publication statusPublished - 25 Nov 2008

Keywords

  • Communication training
  • Death and dying
  • Do-not-resuscitate orders
  • Palliative care

Cite this

Levin, Tomer T. ; Li, Yuelin ; Weiner, Joseph S. ; Lewis, Frank B.S. ; Bartell, Abraham M.D. ; Piercy, Jessica B.A. ; Kissane, David W. / How do-not-resuscitate orders are utilized in cancer patients : Timing relative to death and communication-training implications. In: Palliative and Supportive Care. 2008 ; Vol. 6, No. 4. pp. 341-348.
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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.",
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How do-not-resuscitate orders are utilized in cancer patients : Timing relative to death and communication-training implications. / Levin, Tomer T.; Li, Yuelin; Weiner, Joseph S.; Lewis, Frank B.S.; Bartell, Abraham M.D.; Piercy, Jessica B.A.; Kissane, David W.

In: Palliative and Supportive Care, Vol. 6, No. 4, 25.11.2008, p. 341-348.

Research output: Contribution to journalArticleResearchpeer-review

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AU - Levin, Tomer T.

AU - Li, Yuelin

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AU - Bartell, Abraham M.D.

AU - Piercy, Jessica B.A.

AU - Kissane, David W.

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N2 - 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.

AB - 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.

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