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



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.


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.


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.


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.


  1. 1.

    Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A (2018) Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 68:394–424. https://doi.org/10.3322/caac.21492

    Article  Google Scholar 

  2. 2.

    Santonocito C, Ristagno G, Gullo A, Weil MH (2013) Do-not-resuscitate order: a view throughout the world. J Crit Care 28:14–21. https://doi.org/10.1016/j.jcrc.2012.07.005

    Article  PubMed  Google Scholar 

  3. 3.

    Shih T, Chang H, Lin M, Chen CK, Chen TJ, Hwang SJ (2017) Trends of do-not-resuscitate orders, hospice care utilization, and late referral to hospice care among cancer decedents in a tertiary hospital in Taiwan between 2008 and 2014: a hospital-based observational study. J Palliat Med 20:838–844. https://doi.org/10.1089/jpm.2016.0362

    Article  PubMed  Google Scholar 

  4. 4.

    Han X, Zhou Y, Wang L, He Y (2015) Factors influencing the place of death in Beijing Dongcheng South District patients with cancer, 2007-2012. J Med Res (Chinese) 44:57–60. https://doi.org/10.11969/j.issn.1673-548X.2015.05.015

    Article  Google Scholar 

  5. 5.

    Kagawasinger M, Blackhall LJ (2001) Negotiating cross-cultural issues at the end of life - "you got to go where he lives". JAMA 286:2993–3001. https://doi.org/10.1001/jama.286.23.2993

    CAS  Article  Google Scholar 

  6. 6.

    Su YC (2014) When ethical reform became law: the constitutional concerns raised by recent legislation in Taiwan. J Med Ethics 40:484–487. https://doi.org/10.1136/medethics-2013-101599

    Article  PubMed  Google Scholar 

  7. 7.

    National Health Commission of the People’s Republic of China (2017) Notice of the National Health and Family Planning Commission on issuing the basic standards and management rules of the hospice care center (Trial implementation). http://www.nhc.gov.cn/yzygj/s3593/201702/2f50fdc62fa84cdd9d9a09d5162a661f.shtml. Accessed 19 December 2019

  8. 8.

    National Health Commission of the People’s Republic of China (2017) Notice of the National Health and Family Planning Commission of PRC on the issuance of guidelines for the practice of hospice care (Trial Implementation). http://www.nhc.gov.cn/yzygj/s3593/201702/3ec857f8c4a244e69b233ce2f5f270b3.shtml. Accessed 19 December 2019

  9. 9.

    Ning XH (2019) Hospice and palliative care research in mainland China: current status and future direction. Palliat Med 33:1127–1128. https://doi.org/10.1177/0269216319857495

    Article  PubMed  Google Scholar 

  10. 10.

    Beijing Living Will Promotion Association (2013). Choice and Dignity. https://www.lwpa.org.cn/Index.shtml. Accessed 19 December 2019

  11. 11.

    Beijing Living Will Promotion Association (2013) Choice and dignity. My five wishes. https://www.lwpa.org.cn/Pub/s/129/461.shtml. Accessed 19 December 2019

  12. 12.

    Cheng YH, Wang JJ, Wu KH, Huang S, Kuo ML, Su CH (2016) Do-not-resuscitate orders and related factors among family surrogates of patients in the emergency department. Support Care Cancer 24:1999–2006. https://doi.org/10.1007/s00520-015-2971-7

    Article  PubMed  Google Scholar 

  13. 13.

    Crosby MA, Cheng L, DeJesus AY, Travis EL, Rodriguez MA (2016) Provider and patient gender influence on timing of do-not-resuscitate orders in hospitalized patients with cancer. J Palliat Med 19:728–733. https://doi.org/10.1089/jpm.2015.0388

    Article  PubMed  Google Scholar 

  14. 14.

    Xing YF, Lin JX, Li X, Lin Q, Ma XK, Chen J, Wu DH, Wei L, Yin LH, Wu XY (2017) Advance directives: cancer patients' preferences and family-based decision making. Oncotarget 8:45391–45398. https://doi.org/10.18632/oncotarget.17525

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Zhang Z, Chen ML, Gu XL, Liu MH, Cheng WW (2015) Cultural and ethical considerations for cardiopulmonary resuscitation in Chinese patients with cancer at the end of life. Am J Hosp Palliat Care 32:210–215. https://doi.org/10.1177/1049909113520215

    Article  PubMed  Google Scholar 

  16. 16.

    Huang B, Chen H, Deng Y, Yi T, Wang Y, Jiang Y (2016) Diagnosis, disease stage, and distress of Chinese cancer patients. Ann Transl Med 4:73. https://doi.org/10.3978/j.issn.2305-5839.2016.02.08

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Torke AM, Sachs GA, Helft PR, Petronio S, Purnell C, Hui S, Callahan CM (2011) Timing of do-not-resuscitate orders for hospitalized older adults who require a surrogate decision-maker. J Am Geriatr Soc 59:1326–1331. https://doi.org/10.1111/j.1532-5415.2011.03480.x

    Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Wong SY, Lo SH, Chan CH, Chui HS, Sze WK, Tung Y (2012) Is it feasible to discuss an advance directive with a Chinese patient with advanced malignancy? A prospective cohort study. Hong Kong Med J 18:178–185

    CAS  PubMed  Google Scholar 

  19. 19.

    Beach MC, Morrison RS (2002) The effect of do-not-resuscitate orders on physician decision-making. J Am Geriatr Soc 50:2057–2061. https://doi.org/10.1046/j.1532-5415.2002.50620.x

    Article  PubMed  Google Scholar 

  20. 20.

    Charlson ME, Charlson RE, Peterson JC, Marinopoulos SS, Briggs WM, Hollenberg JP (2008) The Charlson comorbidity index is adapted to predict costs of chronic disease in primary care patients. J Clin Epidemiol 61:1234–1240. https://doi.org/10.1016/j.jclinepi.2008.01.006

    Article  PubMed  Google Scholar 

  21. 21.

    Phua J, Kee AC, Tan A, Mukhopadhyay A, See KC, Aung NW, Seah AST, Lim TK (2011) End-of-life care in the general wards of a Singaporean hospital: an Asian perspective. J Palliat Med 14:1296–1301. https://doi.org/10.1089/jpm.2011.0215

    Article  PubMed  Google Scholar 

  22. 22.

    Kizawa Y, Tsuneto S, Hamano J, Nagaoka H, Maeno T, Shima Y (2013) Advance directives and do-not-resuscitate orders among patients with terminal cancer in palliative care units in Japan: a nationwide survey. Am J Hosp Palliat Care 30:664–669. https://doi.org/10.1177/1049909112462860

    Article  PubMed  Google Scholar 

  23. 23.

    Park SY, Phua J, Nishimura M, Deng Y, Kang Y, Tada K, Koh Y, Asian Collaboration for Medical Ethics (ACME) Study Collaborators and the Asian Critical Care Clinical Trials (ACCCT) Group (2018) End-of-life care in ICUs in east Asia: a comparison among China, Korea, and Japan. Crit Care Med 46:1114–1124. https://doi.org/10.1097/CCM.0000000000003138

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    McDonald JC, du Manoir JM, Kevork N, Le LW, Zimmermann C (2017) Advance directives in patients with advanced cancer receiving active treatment: attitudes, prevalence, and barriers. Support Care Cancer 25:523–531. https://doi.org/10.1007/s00520-016-3433-6

    Article  PubMed  Google Scholar 

  25. 25.

    Tseng YP, Huang LH, Hsu LL, Huang TH, Hsieh SI, Chi SF, Chou YF (2018) The family surrogates' psychological experience of making a do-not-resuscitate decision for older relatives: a qualitative study. Contemp Nurse 54:195–207. https://doi.org/10.1080/10376178.2018.1478232

    Article  PubMed  Google Scholar 

  26. 26.

    Shen MJ, Trevino KM, Prigerson HG (2018) The interactive effect of advanced cancer patient and caregiver prognostic understanding on patients' completion of do not resuscitate orders. Psychooncology 27:1765–1771. https://doi.org/10.1002/pon.4723

    Article  PubMed  PubMed Central  Google Scholar 

  27. 27.

    Stern SG, Orlowski JP (1992) DNR or CPR-the choice is ours. Crit Care Med 20:1263–1272. https://doi.org/10.1097/00003246-199209000-00013

    CAS  Article  PubMed  Google Scholar 

  28. 28.

    Ho BJ, Akhileswaran R, Pang GSY, Koh GCH (2017) An 11-year study of home hospice service trends in Singapore from 2000 to 2010. J Palliat Med 20:461–472. https://doi.org/10.1089/jpm.2016.0268

    Article  PubMed  Google Scholar 

  29. 29.

    Wuensch A, Tang L, Goelz T, Zhang Y, Stubenrauch S, Song L, Hong Y, Zhang H, Wirsching M, Fritzsche K (2013) Breaking bad news in China--the dilemma of patients' autonomy and traditional norms. A first communication skills training for Chinese oncologists and caretakers. Psychooncology 22:1192–1195. https://doi.org/10.1002/pon.3112

    Article  PubMed  Google Scholar 

  30. 30.

    Ryu JY, Bae H, Kenji H, Xiaomei Z, Kwon I, Ahn KJ (2016) Physicians' attitude toward the withdrawal of life-sustaining treatment: a comparison between Korea, Japan, and China. Death Stud 40:630–637. https://doi.org/10.1080/07481187.2016.1203375

    Article  PubMed  Google Scholar 

  31. 31.

    Nie X, Ye D, Wang Q, Manyande A, Yang L, Qiu H, Chao T, Zhang P, Gong C, Zhuang L, Yu S, Xiong H (2016) Poor-prognosis disclosure preference in cancer patient-caregiver dyads and its association with their quality of life and perceived stress: a cross-sectional survey in mainland China. Psychooncology 25:1099–1105. https://doi.org/10.1002/pon.4055

    Article  PubMed  Google Scholar 

  32. 32.

    Yi TW, Deng YT, Chen HP, Zhang J, Liu J, Huang BY, Wang YQ, Jiang Y (2016) The discordance of information needs between cancer patients and their families in China. Patient Educ Couns 99:863–869. https://doi.org/10.1016/j.pec.2015.12.022

    Article  PubMed  Google Scholar 

  33. 33.

    Zhou W, Mao J, Wen Q, Chen FJ, Ni P (2018) Consistency in attitudes toward advance directive and life sustaining treatments between end-of-life cancer patients and their family members. Chin J Nurs (Chinese) 53:27–32. https://doi.org/10.3761/j.issn.0254-1769.2018.01.006

    Article  Google Scholar 

  34. 34.

    Chen LT, Hsiao FH (2019) The effects of the interventions on the DNR designation among cancer patients: a systematic review. Palliat Support Care 17:95–106. https://doi.org/10.1017/S1478951518000196

    Article  PubMed  Google Scholar 

  35. 35.

    McCaughan D, Roman E, Smith AG, Garry AC, Johnson MJ, Patmore RD, Howard MR, Howell DA (2019) Haematology nurses' perspectives of their patients' places of care and death: a UK qualitative interview study. Eur J Oncol Nurs 39:70–80. https://doi.org/10.1016/j.ejon.2019.02.003

    Article  PubMed  PubMed Central  Google Scholar 

  36. 36.

    McCaughan D, Roman E, Smith AG, Garry AC, Johnson MJ, Patmore RD, Howard MR, Howell DA (2019) Perspectives of bereaved relatives of patients with haematological malignancies concerning preferred place of care and death: a qualitative study. Palliat Med 33:518–530. https://doi.org/10.1177/0269216318824525

    Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Gu X, Cheng W, Cheng M, Liu M, Zhang Z (2015) The preference of place of death and its predictors among terminally ill patients with cancer and their caregivers in China. Am J Hosp Palliat Care 32:835–840. https://doi.org/10.1177/1049909114542647

    Article  PubMed  Google Scholar 

  38. 38.

    Nilsson J, Berglund A, Bergström S, Bergqvist M, Lambe M (2017) The role of comorbidity in the management and prognosis in nonsmall cell lung cancer: a population-based study. Acta Oncol 56:949–956. https://doi.org/10.1080/0284186X.2017.1324213

    Article  PubMed  Google Scholar 

  39. 39.

    Loggers ET, Maciejewski PK, Jimenez R, Nilsson M, Paulk E, Stieglitz H, Prigerson HG (2013) Predictors of intensive end-of-life and hospice care in Latino and white advanced cancer patients. J Palliat Med 16:1249–1254. https://doi.org/10.1089/jpm.2013.0164

    Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    Hsu NC, Huang CC, Chen WC, Yu CJ (2019) Impact of patient-centred and family-centred care meetings on intensive care and resource utilisation in patients with terminal illness: a single-Centre retrospective observational study in Taiwan. BMJ Open 9:e021561. https://doi.org/10.1136/bmjopen-2018-021561

    Article  PubMed  PubMed Central  Google Scholar 

  41. 41.

    Emiloju OE, Djibo DAM, Ford JG (2019) Association between the timing of goals-of-care discussion and hospitalization outcomes in patients with metastatic cancer. Am J Hosp Palliat Care 37:433–438. https://doi.org/10.1177/1049909119882891

    Article  PubMed  Google Scholar 

  42. 42.

    Stream S, Nolan A, Kwon S, Constable C (2018) Factors associated with combined do-not-resuscitate and do-not-intubate orders: a retrospective chart review at an urban tertiary care center. Resuscitation 130:1–5. https://doi.org/10.1016/j.resuscitation.2018.06.020

    Article  PubMed  PubMed Central  Google Scholar 

  43. 43.

    Wang Z, Li YS, Zhao N, Yang JJ, Tu HY, Wu YL (2016) Do-not-resuscitate orders among advanced-stage Chinese lung cancer patients who died in hospital. Support Care Cancer 24:1763–1769. https://doi.org/10.1007/s00520-015-2966-4

    Article  PubMed  Google Scholar 

  44. 44.

    Dong F, Zheng R, Chen X, Wang Y, Zhou H, Sun R (2016) Caring for dying cancer patients in the Chinese cultural context: a qualitative study from the perspectives of physicians and nurses. Eur J Oncol Nurs 21:189–196. https://doi.org/10.1016/j.ejon.2015.10.003

    Article  PubMed  Google Scholar 

  45. 45.

    Azad AA, Siow S, Tafreshi A, Moran J, Franco M (2014) Discharge patterns, survival outcomes, and changes in clinical management of hospitalized adult patients with cancer with a do-not-resuscitate order. J Palliat Med 17:776–781. https://doi.org/10.1089/jpm.2013.0554

    Article  PubMed  Google Scholar 

  46. 46.

    Liu T, Wen F, Wang C, Hong RL, Chow JM, Chen JS, Chiu CF, Tang ST (2017) Terminally ill Taiwanese cancer patients’ and family caregivers’ agreement on patterns of life-sustaining treatment preferences is poor to fair and declines over a decade: results from two independent cross-sectional studies. J Pain Symptom Manag 54:35–45. https://doi.org/10.1016/j.jpainsymman.2017.02.013

    Article  Google Scholar 

  47. 47.

    Amano K, Morita T, Koshimoto S, Uno T, Katayama H, Tatara R (2018) Eating-related distress in advanced cancer patients with cachexia and family members: a survey in palliative and supportive care settings. Support Care Cancer 27:2869–2876. https://doi.org/10.1007/s00520-018-4590-6

    Article  PubMed  Google Scholar 

  48. 48.

    Wilcox SR, Richards JB, Stevenson EK (2019) Association between do not resuscitate/do not intubate orders and emergency medicine residents' decision making. J Emerg Med S0736-4679:30816–30819. https://doi.org/10.1016/j.jemermed.2019.09.033

    Article  Google Scholar 

  49. 49.

    Vivat B, Bemand-Qureshi L, Harrington J, Davis S, Stone P (2019) Palliative care specialists in hospice and hospital/community teams predominantly use low doses of sedative medication at the end of life for patient comfort rather than sedation: findings from focus groups and patient records for I-CAN-CARE. Palliat Med 33:578–588. https://doi.org/10.1177/0269216319826007

    Article  PubMed  PubMed Central  Google Scholar 

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


No funding was received.

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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.

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