The Do-Not-Resuscitate Order: Incidence of Documentation in the Medical Records of Cancer Patients Referred for Palliative Radiotherapy

Abstract

Patients with symptomatic metastases referred for outpatient palliative radiotherapy for symptom control at the Rapid Response Radiotherapy Program (rrrp) and the Bone Metastases Clinic (bmc) at the Toronto–Sunnybrook Regional Cancer Centre have a limited life expectancy. Relevant medical information is missing from the files of many referred patients when they arrive at the clinics, potentially causing delayed treatment and ambiguity in the best management of their needs in situations of worsening condition. Clear documentation of the do-not-resuscitate (dnr) order is imperative to avoid panic and the taking of unnecessarily aggressive measures in situations in which cardiopulmonary resuscitation (cpr) has no benefit or is not desired. Here, we report the current practices of cpr code status documentation for patients referred to the rrrp and the bmc for outpatient palliative radiotherapy. We reviewed referral notes and accompanying medical records for 209 consecutive patients seen in the rrrp and the bmc during May–August 2004 for documentation of cpr-related advance directives. Patient demographics and cancer history were also recorded. Only 13 (6.2%) of the 209 patients had any documented reference to cpr code status. Of these 13 patients, 8 were dnr-coded, and 5 were full code. As compared with patients having no documented cpr code status, patients with documented status were significantly older (median age: 77 years; p = 0.0347), had poorer performance status (median Karnofsky performance status score: 40; p = 0.0001), and were more likely to be referred hospital inpatients (69%, p = 0.0004). Only a small proportion of symptomatic advanced cancer patients had any documentation of cpr code status upon referral for outpatient palliative radiotherapy. In future, our clinics plan to request information about cpr code status on our referral form.

Changing Rates of Goals of Care Designations in Patients With Advanced Pancreatic Cancer During a Multifactorial Advanced Care Planning Initiative: A Real-World Evidence Study

“…We observed a rate of GoC designation documentation comparable with other retrospective studies in patients with advanced cancer, 6,7,10,13,14,16,17 which reported rates as low as 6% and as high as 80%. The two studies with the highest overall rates of documentation (73% and 80%) noted that the majority of conversations happened when patients were admitted to hospital.…”

Documenting Goals of Care Among Patients With Advanced Cancer: Results of a Quality Improvement Initiative

“…2,3 ASCO and the National Cancer Comprehensive Network recommend that these patients also be considered for early referral to palliative care (PC) 3,4 . Despite these guidelines, studies have shown that the rates of GOC documentation [5][6][7] and PC referral 8,9 are low in many institutions. A recent audit of patients with metastatic lung, pancreatic, colon, and breast cancer receiving palliative chemotherapy at the Cancer Centre of Southeastern Ontario (CCSEO) between 2010 and 2015 revealed that only 6% of patients had a documented GOC discussion and only 47% of patients had been referred to PC.…”

Impact of High-Quality Goals-of-Care Discussions on Oncologist Productivity

“…Overall, the 72% prevalence of high-quality GoC discussions reported by patients was higher than we expected and has been reported in the literature. [21][22][23] Shockingly, despite wide differences in patient, oncologist, and hospital characteristics as well as productivity across sites, productivity did not change whether high-quality GoC discussions did or did not take place. Moreover, no difference in the prevalence of high-quality GoC discussions was found between the intervention and usual care group oncologists, despite a more intense training intervention oncologists received in conducting GoC discussions.…”