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

Abstract

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.