The timing of do-not-resuscitate orders and hospital costs

Abstract

The relation between the timing of do-not-resuscitate (DNR) orders and the cost of medical care is not well understood. This prospective observational study compares hospital costs and length of stay of 265 terminally ill patients with admission DNR orders, delayed DNR orders (occurring after 24 hours), or no DNR orders (full code). Patients whose orders remained full code throughout a hospital stay had similar lengths of stay, total hospital costs, and daily costs as patients with admission DNR orders. Patients with delayed DNR orders, by contrast, had a greater mortality, longer length of stay, and higher total costs than full code or admission DNR patients, but similar daily costs. The causes of delay in DNR orders and the associated higher costs are a matter for future research. C urrent knowledge about the influence of do-notresuscitate (DNR) orders on health care costs is inconclusive. 1-4 Although 27% to 30% of all Medicare expenses occur in the last year of life, 5 we do not know how much of this care, if any, is unnecessary. 6,7 One review cast doubt on whether we could reduce costs by limiting end-of-life care, arguing that most such expenses are unavoidable. 8 Others argue, however, that setting explicit limits on high-tech care of the dying is a good first step toward containing costs of marginally beneficial care. 9 Most studies of the resource implications of DNR orders have been retrospective, identifying patients by a known outcome of death or DNR orders, and therefore subject to selection bias. 3,4,10 This study prospectively compares the hospital costs of terminally ill patients who have admission DNR orders, delayed DNR orders (those occurring after 24 hours), and full code status. METHODS Settings and SubjectsThis study identified patients with four diagnoses that have a high expected 1-year mortality (30%-60%) [11][12][13][14] : AIDS patients with a T4 cell count of less than 50 cells/ mm 3 ; patients with unresectable lung cancer; patients with severe chronic congestive heart failure (CHF); and nursing home patients with dementia and malnutrition (malnutrition defined as serum albumin Ͻ 3.5 mg/dL). Study Design and MeasurementsThe study protocol was approved by institutional review boards at each hospital. A DNR order was defined as a written order that a patient not receive cardiopulmonary resuscitation or intubation. Data included diagnosis, DNR status during the hospital stay, age, gender, race, type of attending physician (generalist or specialist), hospital site, insurance type, APACHE III score on admission, 15 and hospital survival. Economic variables included length of stay, total physician and hospital costs, and daily costs. For each physician fee, a resource-based relative value scale value was multiplied by a Medicare conversion factor to arrive at actual costs. 16 At the university hospital, a cost-accounting office provided a summary of daily hospital costs. At the community hospital, each charge was multiplied by a charge-to-cost ratio. Addition of physician and hospital cost...

CPR or DNR? End-of-life decision in Korean cancer patients: a single center’s experience

“…It has a social impact, in view of the limited medical resource. In the study of De Jonge et al [20], delayed DNR order (occurring after 24 h of admission) resulted in a higher total medical cost than admission DNR patients. According to Bock et al [21], prompt and early DNR decisions could lead to substantial savings.…”

Obstacles to Palliation and End-of-Life Care in a Long-Term Care Facility

“…We suggested in our earlier work that orders for hospice care and similar end-of-life care may be symbolic "medical last rites" (DeJonge, Sulmasy, & Gold, 1999) for long-term care residents and family members . These approaches to managing end-of-life care can be partially attributed to a general unwillingness to embrace the naturalness of dying in American society (Lawhorne, 1999;Lederberg, 1997;McCue, 1995).…”

Compliance with DNR policy in a tertiary care center in Saudi Arabia

“…The ICU physician initiated DNR status immediately in 20% of cases, suggesting a delay in initiating DNR, as the MRP accepted DNR in all but one case. In a previous study, delayed DNR proved to cause higher costs and poor outcomes and to incur longer length of stay compared to patients in whom DNR status was addressed on admission [10].…”