“Allow natural death” versus “Do not resuscitate”: What do patients with advanced cancer choose?

2014 ◽  
Vol 32 (31_suppl) ◽  
pp. 89-89
Author(s):  
Milos Miljkovic ◽  
Dennis Omoding Emuron ◽  
Lori Rhodes ◽  
Joseph Abraham ◽  
Kenneth David Miller
Keyword(s):  
End Of Life ◽  
Advanced Cancer ◽  
Cancer Education ◽  
Living Will ◽  
Tube Placement ◽  
Similar Proportion ◽  
Do Not Resuscitate ◽  
Natural Death ◽  
Code Status ◽  
Dnr Orders

89 Background: Many patients with advanced cancer at our hospital request full resuscitative efforts at the end of life. In the first in a series of quality improvement projects to improve end-of-life (EOL) care, we assessed the knowledge and attitudes of patients towards it to determine if “Allow Natural Death” (AND) orders were more acceptable than “Do Not Resuscitate” (DNR) orders. Methods: Adult patients with advanced cancer being treated at a single community hospital were invited to participate. The first 100 consenting patients were surveyed regarding their diagnosis, prognosis, and attitudes about critical care and resuscitation. They were then presented with hypothetical scenarios in which a decision on their code status had to be made if they had 1 year, 6 months or 1 month left to live. Fifty patients were given a choice between being “full code“ and “DNR”, and 50 could choose between ”full code" and “AND”. Results: Participants were equally likely to choose either of the “no code” options in all hypothetical scenarios (p > 0.54). The choice was not affected by age, sex, race, type of cancer, education, or income level. Patients who said they would want life-prolonging measures such as CPR, tracheostomies, and feeding tube placement in case of a permanent vegetative state were significantly less likely to choose “AND” than “full code” (p=0.001–0.002). A similar proportion of patients who had a living will chose “AND” and “DNR” orders instead of “full code” in all the scenarios (47–74% and 63–71%). In contrast, among patients who did not have a living will 52% chose “DNR”, while 19% opted for “AND”. More than a third (39 of 93) patients were not aware their illness was terminal. Conclusions: We hypothesized that “AND” orders may be more acceptable to patients with advanced cancer, but the wording of the “no code” order does not seem to be related to the patients’ code status decisions. The “Do not resuscitate” phrasing may be more acceptable to patients who view life-prolonging measures favorably.

Are “Allow Natural Death” orders preferable to “Do Not Resuscitate” orders for patients with advanced cancer?

2013 ◽  
Vol 31 (15_suppl) ◽  
pp. e20685-e20685
Author(s):  
Dennis Omoding Emuron ◽  
Milos Miljkovic ◽  
Lori Rhodes ◽  
Joseph Abraham ◽  
Kenneth David Miller
Keyword(s):  
Advanced Cancer ◽  
Cancer Education ◽  
Living Will ◽  
Small Sample ◽  
Do Not Resuscitate ◽  
Natural Death ◽  
P Values ◽  
Feeding Tubes ◽  
Code Status ◽  
Eol Care

e20685 Background: Over twenty years after the passage of the Patient Self-Determination Act, patients’ preferences regarding end-of-life (EOL) care are often unknown to physicians. The aim of this study was to assess the knowledge and attitudes of cancer patients regarding EOL care, and to compare “Do Not Resuscitate” (DNR) and “Allow Natural Death” (AND) orders. Methods: Adult patients with advanced cancer were invited to participate. The first 50 consenting patients were surveyed regarding their prognosis and attitudes about critical care and resuscitation. We presented them with hypothetical scenarios in which a decision on their code status had to be made if they had 1 year, 6 months or 1 month left to live. Twenty-five patients were given a choice between being “full code" and DNR, and then 25 patients had a choice between "full code" and AND. Results: Almost half the patients (49%) were not aware that their illness was terminal. Fifty percent reported having a living will. However, only 19% reported that their doctors knew their wishes regarding EOL care. In contrast, greater than 78% reported knowledge of intubation, tracheotomy, feeding tubes, and cardiopulmonary resuscitation (CPR). The proportions of participants choosing full resuscitation compared to the DNR or AND options did not differ significantly from 50% (p-values > 0.54). Their choices did not vary by age, sex, race, type of cancer, education or income level (p-values > 0.05). Patients' attitudes towards CPR, tracheostomy and feeding tubes were not significantly associated with their choice of "DNR" (p-values > 0.17), but those who wanted these interventions were significantly less likely to choose "AND" (p-values < 0.002). As many as 38% of the patients without a living will chose "DNR", while 11% opted for "AND" (p-values < 0.03). Conclusions: In this small sample of patients with advanced cancer many were unaware of their poor prognosis, and few informed their physicians of their EOL preferences. The wording of DNR and AND orders was not associated with patients' EOL preferences. Contrary to our expectation, the "Allow Natural Death" phrasing might be less acceptable to patients who view life-prolonging measures favorably.

Clinician Perspectives on Challenges to Patient Centered Care at the End of Life

2016 ◽  
Vol 36 (4) ◽  
pp. 401-415 ◽  
Author(s):  
Shoshana H. Bardach ◽  
Edward J. Dunn ◽  
J. Christopher Stein
Keyword(s):  
End Of Life ◽  
Medical Center ◽  
Local Policy ◽  
Do Not Resuscitate ◽  
Patient Centered ◽  
Code Status ◽  
Respiratory Therapists ◽  
Centered Care ◽  
Preventive Ethics ◽  
Dnr Orders

Discussions regarding patient preferences for resuscitation are often delayed and preferences may be neglected, leading to the receipt of unwanted medical care. To better understand barriers to the expression and realization of patients’ end of life wishes, a preventive ethics team in one Veterans Affairs Medical Center conducted a survey of physicians, nurses, social workers, and respiratory therapists. Surveys were analyzed through qualitative analysis, using sorting methodologies to identify themes. Analysis revealed barriers to patient wishes being identified and followed, including discomfort conducting end-of-life discussions, difficulty locating patients’ preferences in medical records, challenges with expiring do not resuscitate (DNR) orders, and confusion over terminology. Based on these findings, the preventive ethics team proposed new terminology for code status preferences, elimination of the local policy for expiration of DNR orders, and enhanced systems for storing and retrieving patients’ end-of-life preferences. Educational efforts were initiated to facilitate implementation of the proposed changes.

scholarly journals Impact of palliative care consultation on end-of-life care measures: A retrospective analysis of patients in the Oncology Care Model.

2019 ◽  
Vol 37 (27_suppl) ◽  
pp. 45-45
Author(s):  
Alison Greidinger ◽  
Maria Vershvovsky ◽  
Evan Lapinsky ◽  
Alison Rhoades ◽  
Amy Leader ◽  
...  
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Acute Care ◽  
Advanced Cancer ◽  
Cancer Center ◽  
Do Not Resuscitate ◽  
Care Model ◽  
Code Status ◽  
Palliative Care Consultation ◽  
Oncology Care

45 Background: Despite a 2016 ASCO recommendation that patients with advanced cancer receive dedicated palliative care (PC) services, many patients are not referred and continue to receive chemotherapy and utilize high-acuity services near the end of life (EOL). Studies suggest that early PC involvement is associated with lower spending, acute care utilization, and chemotherapy administration at the EOL. The Sidney Kimmel Cancer Center participates in the Oncology Care Model (OCM), a CMS episode-based alternative payment model promoting high-value care. Using OCM-generated data, we evaluated the effect of PC visits on EOL outcomes. Methods: We identified OCM patients with episodes starting April 1, 2016-July 1, 2018 with GI and head & neck malignancies who had died, and determined whether patients who saw a PC provider had greater documentation of a code status (CS) before death, as well as lower spending and utilization of chemotherapy or acute care in the last 30 days of life. CMS spending data and dates of death were derived from OCM quarterly feedback, while all other data was compiled via chart review. CS was recorded at the start of the episode and at the time of death. Results: The study included 126 patients (median age 66 years), of whom 38% had a PC visit. 24% had only an inpatient (IP) PC consult, 6% only an outpatient (OP) visit, and 9% both IP & OP visits. More patients who saw PC had an initial CS documented (85%, vs 46% for no PC), and had a greater proportional increase in CS documentation before death (96% vs 53%). Despite similar rates at baseline, the final CS was significantly more likely to be “Do Not Resuscitate/Intubate” (DNR/DNI) among PC patients (79%, vs 28% for no PC). An initial CS of DNR/DNI was associated with lower mean ICU and total non-hospice spending in the last 30 days of life. Conclusions: This retrospective study in OCM patients found that PC intervention is associated with improved documentation of a CS and higher rates of DNR/DNI documentation before death. There is an association between an initial DNR/DNI CS and lower acute care spending. This data suggests a beneficial effect of early PC on utilization at the EOL in advanced cancer patients.

Randomized Controlled Trial of a Structured Intervention to Facilitate End-of-Life Decision Making in Patients With Advanced Cancer

2013 ◽  
Vol 31 (27) ◽  
pp. 3403-3410 ◽  
Author(s):  
Rhea A. Stein ◽  
Louise Sharpe ◽  
Melanie L. Bell ◽  
Fran M. Boyle ◽  
Stewart M. Dunn ◽  
...  
Keyword(s):  
Decision Making ◽  
End Of Life ◽  
Outcome Measures ◽  
Advanced Cancer ◽  
Secondary Outcome ◽  
Hospital Death ◽  
Do Not Resuscitate ◽  
End Of Life Decision ◽  
Life Decision ◽  
Dnr Orders

Purpose This study tested the efficacy of an intervention on end-of-life decision making for patients with advanced cancer. Patients and Methods One hundred twenty patients with metastatic cancer who were no longer being treated with curative intent (and 87 caregivers) were randomly assigned to the intervention (n = 55) or treatment as usual (n = 65). Primary outcome measures were the proportion of patients with do-not-resuscitate (DNR) orders, timing of DNR orders, and place of death. Secondary outcome measures were completed at study enrollment, 3 weeks later, and 3 months later, including patients' knowledge, mood, and caregiver burden. Results High, but equivalent, rates of DNR orders were observed in both groups. In per-protocol analyses, DNR orders were placed earlier for patients who received the intervention (median, 27 v 12.5 days; 95% CI, 1.1 to 5.9; P = .03) and they were more likely to avoid a hospital death (19% v 50% (95% CI, 11% to 50%; P = .004). Differences between the groups over time were evident for estimates of cardiopulmonary rehabilitation (CPR) success rates (P = .01) but not knowledge of CPR (P = .2). There was no evidence that the intervention resulted in more anxious or depressive symptoms. Caregivers experienced less burden in terms of disruption to schedule if the patient received the intervention (P = .05). Conclusion An intervention, consisting of an informational pamphlet and discussion, was associated with earlier placement of DNR orders relative to death and less likelihood of death in hospital. There was no negative impact of the intervention on secondary outcomes, although the sample may have been too small to detect differences.

scholarly journals L’utilisation des échelles de niveaux d’interventions médicales en centre hospitalier

2016 ◽  
Vol 35 (1) ◽  
pp. 70-78
Author(s):  
Marjolaine Frenette ◽  
Jocelyne Saint-Arnaud
Keyword(s):  
Decision Making ◽  
End Of Life ◽  
End Of Life Care ◽  
Treatment Options ◽  
Medical Intervention ◽  
Treatment Withdrawal ◽  
Decision Making Process ◽  
Do Not Resuscitate ◽  
Code Status ◽  
Levels Of Care

ABSTRACTDifferent care settings in Quebec use levels of medical intervention forms, also called levels of care (LOC), to determine the code status of patients and to improve end-of-life care planning. It is not currently possible to know whether the levels of care in hospitals benefit patients and staff in facilitating the decision making process of treatment options and resuscitation measures. No study, to the best of the authors’ knowledge, has been published about LOC, particularly in Quebec and Canada. This literature review was undertaken on levels of care in order to clarify this topic. Relevant articles are discussed under different themes that are pertinent to LOC. The themes addressed in this article include care at the end of life, do-not-resuscitate orders, treatment withdrawal, and decision making at end of life.

Assessment of end-of-life care quality indicators in veterans with cancer.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. e18327-e18327
Author(s):  
Giselle Alexandra Suero-Abreu ◽  
Camille Michelle Johnson ◽  
Marshall McKenna ◽  
Jun Chih Wang ◽  
Aldo Barajas-Ochoa ◽  
...  
Keyword(s):  
End Of Life ◽  
Acute Care ◽  
Care Quality ◽  
Do Not Resuscitate ◽  
Next Of Kin ◽  
Care Services ◽  
Pain Medications ◽  
New Treatment ◽  
Assess Quality ◽  
Dnr Orders

e18327 Background: Many cancer patients (pts) receive aggressive medical care at the end-of-life (EOL) . The objective of this study was to assess quality of EOL (qEOL) care in cancer pts at our VA and to determine the implementation of do-not-resuscitate (DNR) orders. Methods: Records of Veterans followed at the VA NJ Health Care System who died from 2015-2017 were reviewed. The qEOL care was assessed using seven indicators by Earle et al. ( J Clin Oncol. 2003;21(6):1133-1138). EOL planning (use of DNRs and use of palliative and hospice services) was also assessed. Results: We identified 92 male pts with cancer (mean age 73 years ±10). There were Caucasian (n = 48, 52%) and African American (n = 38, 41%) pts. The most common malignancies were lung (22%), gastrointestinal (21%), prostate (16%) and hematological (14%). 87 pts (95%) had a DNR order at the time of death; the DNR was obtained a median of 60 days prior (IQR 7-135). Ten pts (11%) had DNR orders placed within 1 week of death. Seven pts (8%) received chemotherapy in the last 14 days of life while 6 pts (7%) received a new treatment in their last 30 days. In the last month of life, 35 pts (38%) had multiple hospitalizations and ER visits, 20 pts (22%) were admitted to the intensive care unit, 9 pts (10%) were intubated, and 3 pts [3%] received cardiopulmonary resuscitation. More pts (n = 47, 51%) died in an acute care setting, and 45 (49%) pts were admitted to hospice (median of 22 days before death, IQR 6-52). Four pts (4%) were admitted to hospice within 3 days of death. A next-of-kin was available for 64 pts (70%). Palliative care (PC) was provided to 83 pts (90%) and pain medications prescribed for 80 pts (87%). Conclusions: There was timely implementation of DNRs and referral to PC. The qEOL indicators used suggest that aggressive treatments were appropriately being held at the EOL. However, there was an increased use of acute care services. Limitations include lack of data on Veterans who died outside the VA. This data supports future quality improvement EOL interventions. [Table: see text]

The association between religiosity and resuscitation status preference among patients with advanced cancer

2015 ◽  
Vol 13 (5) ◽  
pp. 1435-1439 ◽  
Author(s):  
Marvin O. Delgado-Guay ◽  
Gary Chisholm ◽  
Janet Williams ◽  
Eduardo Bruera
Keyword(s):  
End Of Life ◽  
Advanced Cancer ◽  
Short Form ◽  
Controlled Trial ◽  
Secondary Analysis ◽  
Religious Faith ◽  
Communication Style ◽  
Do Not Resuscitate ◽  
Advanced Cancer Patients ◽  
Resuscitation Status

AbstractObjective:The potential influence of patient religious and spiritual beliefs on the approach to end-of-life care and resuscitation status preferences is not well understood. The aim of this study was to assess the association between religiosity and resuscitation preferences in advanced-cancer patients.Method:We performed a secondary analysis of a randomized controlled trial that evaluated the influence of physician communication style on patient resuscitation preferences. All patients completed the Santa Clara Strength of Religious Faith Questionnaire–Short Form (SCSRFQ–SF) and expressed their resuscitation preferences. We determined the frequency of resuscitation preferences and its association with intensity of religiosity.Results:A total of 78 patients completed the study. The median age was 54 years, with a range of 18–78. Some 46 (59%) were women; 57 patients (73%) were Caucasian, 15 (19%) African American, and 5 (7%) Hispanic. A total of 46 patients (56%) were Protestant and 13 (17%) Catholic. Some 53 of 60 patients who chose Do Not Resuscitate status (DNR) (88%) and 16 of 18 patients who refused DNR (89%) for a video-simulated patient were highly religious (p = 0.64). When asked about a DNR for themselves after watching the videos, 43 of 48 who refused DNR (90%) and 26 of 30 patients who chose DNR (87%) were highly religious (p = 0.08). The Spearman correlation coefficient for patients choosing DNR for themselves and intensity of religiosity was r = –0.16 (p = 0.16). Some 30 patients (38%) who chose DNR for the video patient refused DNR for themselves, and 42 who chose DNR for both the video patient and themselves (54%) were highly religious (p = NS).Significance of Results:There was no significant association between intensity of patient religiosity and DNR preference for either the video patient or the patients themselves. Other beliefs and demographic factors likely impact end-of-life discussions and resuscitation status preferences.

Dying for advice: Code-status discussions between resident physicians and patients with advanced cancer—A national survey.

2014 ◽  
Vol 32 (31_suppl) ◽  
pp. 83-83
Author(s):  
David Johnson Einstein ◽  
Katherine Levine Einstein ◽  
Paul Mathew
Keyword(s):  
Internal Medicine ◽  
United States ◽  
End Of Life ◽  
Advanced Cancer ◽  
Patient Autonomy ◽  
The United States ◽  
Specific Recommendation ◽  
Code Status ◽  
Resident Physicians ◽  
Treatment Refractory

83 Background: Patients with treatment-resistant advanced cancer rarely benefit from cardiopulmonary resuscitation (CPR) but infrequently discuss end-of-life care with a physician until hospitalized for deterioration. Admitting resident physicians may therefore conduct initial code-status discussions, but may elicit patients’ preferences without providing necessary guidance. Methods: We distributed a case-based survey to all United States internal medicine residency program directors, of whom 19 enrolled and forwarded the survey to their residents. 358 residents (response rate 22.0%) completed the survey. Results: Faced with a hypothetical case of an inpatient with treatment-refractory advanced cancer, nearly all residents felt CPR would not be helpful. Yet, fewer than half (46.7%) of residents were likely to discuss an estimate of prognosis and the value of CPR with the patient. Only 30% were likely to offer a specific recommendation on CPR. A majority (69%) of residents who were unwilling to make a recommendation stated that patients should make their decisions independently. Most residents report that a sense of responsibility is the primary reason to discuss code status independent of attending physicians, and that deference to patient autonomy prevented them from sharing knowledge of outcomes or offering guidance. Ultimately, a minority stated they were satisfied with end-of-life discussions. Conclusions: Internal medicine resident physicians in the United States are unlikely to share the poor prognosis or offer specific recommendations on CPR in treatment-refractory cancer principally because of a conflict with their concept of patient autonomy. Given the futility associated with CPR in this setting, these data define a major unmet need in training and practice.

Full Code to Do-Not-Resuscitate: Culturally Adapted Palliative Care Consultations and Code Status Change Among Seriously Ill Hispanic Patients

2021 ◽  
pp. 104990912110423
Author(s):  
Neela K. Patel ◽  
Stacey A. Passalacqua ◽  
Kylie N. Meyer ◽  
Gabriel A. de Erausquin
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Palliative Care Service ◽  
Do Not Resuscitate ◽  
Code Status ◽  
Palliative Care Consultation ◽  
Culturally Adapted ◽  
Hispanic Patients ◽  
The Impact ◽  
Seriously Ill

Background: Palliative care and hospice services are disproportionately underutilized by ethnic minority patients. Addressing barriers to utilization of these services is critical to reducing disparities. The purpose of this study was to assess the impact of a culturally adapted palliative care consultation service for Hispanics on end-of-life decisions, specifically likelihood of changing from full code to do-not-resuscitate (DNR) status during index admission for serious illness. Methods: A cross-sectional study design was applied to data extracted from electronic health records (EHR) of patients seen by a Geriatric Palliative Care service during inpatient stays between 2018 and 2019. The majority of referrals came from critical care sites. Culturally adapted palliative care consultations using the SPIKES tool featured a Spanish-speaking team member leading discussions, involvement of multiple and key family members, and a chaplain who is a Catholic Priest. Results: The analytic sample included 351 patients who were, on average, 72 years old. 54.42% were female, 59.54% were Hispanic, and of Hispanic patients, 47.37% spoke primarily Spanish. Culturally adapted consults resulted in higher rates of conversion to DNR status in palliative cases of the target population. Both primary language and ethnicity were associated with likelihood of change from full code to DNR status, such that Spanish speakers and those of Hispanic ethnicity were more likely to switch to DNR than non-Hispanics and English-Speakers. Conclusion: This study illustrates how culturally adapted palliative care consultations can help reduce barriers and improve end-of-life decision-making, and can be applied with similar populations of seriously ill Hispanic patients.

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