Advance Directive and Do-Not-Resuscitate Status among Advanced Cancer Patients with Acute Care Surgical Consultation

Abstract

Formal communication of end-of-life preferences is crucial among patients with metastatic cancer. Our objective is to describe the prevalence of advance directives (AD) and do-not-resuscitate (DNR) orders among stage IV cancer patients with acute care surgery consultations, and the associated outcomes. This is a single institution retrospective review over an eight-year period. Two hundred and three patients were identified; mean age was 55.3 ± 11.4 years and 48.8 per cent were male. Fifty (24.6%) patients underwent exploratory surgery. Nineteen (10.6%) patients had another type of surgery. Twenty-one (10.3%) patients had a DNR order, and none had an AD on-admission. Fifty-four (26.6%) patients had a DNR order placed and four (2%) patients completed an AD postadmission. DNR postadmission was associated with the highest mortality at 42.6 per cent compared with 14.3 per cent for DNR on-admission and 1.56 per cent for full-code patients ( P < 0.001). Compared with patients that remained full-code and those with DNR on-admission, DNR postadmission was associated with longer length of stay (19.6 days; P < 0.001) and ICU length of stay (7.72 days; P < 0.001). The prevalence of AD and DNR orders among stage IV cancer patients is low. The higher in-hospital mortality of patients with DNR postadmission reflects the use of DNR orders during clinical decline.

Crucial Conversations for High Risk Populations Before Surgery: Advance Care Planning in a Preoperative Setting

“…Similar to prior studies, in this chart review, approximately 15% of patients had an AD on le 8,9 . Over a quarter of the patients were readmitted in the following year.…”

“…In one study of intensive care unit patients, 42% of patients had an AD, however the cohort was known to be signi cantly ill, with a mortality of 24% 8 . In contrast, another study examining the prevalence of ADs in a cohort of cancer patients undergoing surgery consultation reported 10% of these patients had a Do-Not-Resuscitate order in their medical record but none had an AD on le 9 . Studies have also demonstrated completion of ADs are associated with lower readmission rates 10,11 , which have implications for both individual patients and health systems.…”

Associations Among End-of-Life Discussions, Health-Care Utilization, and Costs in Persons With Advanced Cancer: A Systematic Review

“…Cancer types included breast, 42 hematological, 35,33 gynecological, 1,34,48 lung or gastrointestinal, 39 and any type. 23,31,32,[36][37][38]40,41,43,45,46,48,51 Sample sizes ranged from 84 to 2752 participants, with a median of 226 participants per study. Two studies featured fewer than 100 participants.…”

“…36,37,43 No studies examined the impact of out-of-pocket costs on patients. Eighteen studies assessed relationships between EOL discussions and health-care utilization near death 1,23,[32][33][34][35][38][39][40][41][42][43][45][46][47][48]51 and 6 studies assessed place of death. 1,33,35,42,47,51 In addition, 6 studies incorporated elements of time in their assessment of EOL discussions, generally referring to these discussions as early (31þ days before death) or late (within 30 days of death), with later conversations typically occurring in inpatient settings.…”

“…1,33,35,42,47,51 In addition, 6 studies incorporated elements of time in their assessment of EOL discussions, generally referring to these discussions as early (31þ days before death) or late (within 30 days of death), with later conversations typically occurring in inpatient settings. 1,23,31,41,48…”