Changes in cancer patients’ perceptions of do-not-resuscitate orders as end of life (EOL) approaches

Abstract

8072 Background: In formulating policy on do not resuscitate (DNR) orders we sought patients’ views, postulating that perceptions may change with approaching death. Methods: In consecutive studies patients with cancer had semi-structured interviews recorded, transcribed and subjected to discourse analysis, to find their perceptions of DNR orders. The 1st group was 23 patients with cancer not considered near the end of life; the 2nd was 28 patients within 3 months of dying. Accrual ended when no new issues were arising. Results: Major demographic differences were that in study 1, 61% had stage IV disease, none dying within 6 months whereas in study 2, all had stage VI disease and 82% died within 3 months. Half chose to have others present at interview in study 2 compared to1 in study 1. The 1st group used hypothetical and third-person constructions when discussing EOL decisions where the 2nd used the first-person. DNR orders were on file for 2 of the 1st group but 15 of the 2nd; for 39% of this group, views expressed at interview and what was recorded were not compatible, 9 patients wanting DNR with none recorded, and 2 not wanting DNR but with one on file; 4 expressed views for and against. Both groups assigned the decision to the patient unless cognitively impaired when it was usually delegated to the family who also were seen as having an impact on the decision itself. Generally patients’ emotional states were thought primary in deciding when to discuss EOL issues and in both studies some patients believed this could best be determined by the doctor. Implicit within this are assumptions that DNR discussions imply impending death, and are difficult discussions that should be avoided unless justifiable. In both studies some patients put themselves outside the group to whom DNR orders applied, justified by showing a resistance to death, having something to live for (7 patients in study 2), or claims that they were not sick enough (4 patients expressing this in study 2). Conclusions: Patients closer to death give their own views on EOL decisions rather than treating the issue as hypothetical. Formulating DNR policy will require the ability to accommodate a full range of views including patients who do not wish to discuss DNR orders even when close to death. No significant financial relationships to disclose.