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  • Title: How do-not-resuscitate orders are utilized in cancer patients: timing relative to death and communication-training implications.
    Author: Levin TT, Li Y, Weiner JS, Lewis F, Bartell A, Piercy J, Kissane DW.
    Journal: Palliat Support Care; 2008 Dec; 6(4):341-8. PubMed ID: 19006588.
    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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