Timing of do-not-resuscitate orders and health care utilization near the end of life in cancer patients: a retrospective cohort study

Abstract

Purpose

The objectives are to explore the prevalence of DNR orders, the factors influencing them, and the association between DNR signing and health care utilization among advanced cancer patients.

Methods

This was a retrospective cohort study. Data from cancer decedents in three hospitals in China from January 2016 to December 2017 during their last hospitalization before death were obtained from the electronic medical records system.

Results

In total, 427 cancer patients were included; 59.0% had a DNR order. Patients who had solid tumors, lived in urban areas, had more than one comorbidity, and had more than five symptoms were more likely to have DNR orders. The cut-off of the timing of obtaining a DNR order was 3 days, as determined by the median number of days from the signing of a DNR order to patient death. Patients with early DNR orders (more than 3 days before death) were less likely to be transferred to the intensive care unit and undergo cardiopulmonary resuscitation, tracheal intubation, and ventilation, while they were more likely to be given morphine and psychological support compared with those with late (within 3 days before death) and no orders.

Conclusions

Advanced cancer patients with solid tumors living in urban areas with more symptoms and comorbidities are relatively more likely to have DNR orders. Early DNR orders are associated with less aggressive procedures and more comfort measures. However, these orders are always signed late. Future studies are needed to better understand the timing of DNR orders.

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Data availability

The data supporting the conclusions of this article are included within the article. Comprehensive aggregate data will be shared upon request.

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Acknowledgments

The authors acknowledge the support of all the doctors and nurses who helped us with the study.

Funding

No funding was received.

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Contributions

All authors had access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. CC and CP conceived and designed the study. CP, GX, CY, and DS acquired the data and entered in the database. PZ conducted statistical analysis. CC, CP, WP, BW, and YC interpreted the data. CP drafted the manuscript. WP, BW, and YC revised the manuscript critically for important intellectual content. All authors approved the final version for submitting.

Corresponding author

Correspondence to Changying Chen.

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The authors declare that they have no competing interest.

Ethics approval

The current study was part of an internal hospital project related to the improvement of the quality of end-of-life care; thus, it was exempt from the need for approval by Institutional Review Board of Zhengzhou University.

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We used retrospective and de-identified administrative data, and informed consent was not required.

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Cui, P., Ping, Z., Wang, P. et al. Timing of do-not-resuscitate orders and health care utilization near the end of life in cancer patients: a retrospective cohort study. Support Care Cancer 29, 1893–1902 (2021). https://doi.org/10.1007/s00520-020-05672-x

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Keywords

  • Neoplasm
  • Do-not-resuscitate
  • Influencing factor
  • Timing
  • Health care utilization