Do-not-resuscitate Directives Research Articles

Outcomes of advance care directives after admission to a long-term care home: DNR the DNH?

BackgroundResidents of long-term care homes (LTCH) often experience unnecessary and non-beneficial hospitalizations and interventions near the end-of-life. Advance care directives aim to ensure that end-of-life care respects resident needs and wishes.MethodsIn this retrospective cohort study, we used multistate models to examine the health trajectories associated with Do-Not-Resuscitate (DNR) and Do-Not-Hospitalize (DNH) directives of residents admitted to LTCH in Ontario, Alberta, and British Columbia, Canada. We adjusted for baseline frailty-related health instability. We considered three possible end states: change in health, hospitalization, or death. For measurements, we used standardized RAI-MDS 2.0 LTCH assessments linked to hospital records from 2010 to 2015.ResultsWe report on 123,003 LTCH residents. The prevalence of DNR and DNH directives was 71 and 26% respectively. Both directives were associated with increased odds of transitioning to a state of greater health instability and death, and decreased odds of hospitalization. The odds of hospitalization in the presence of a DNH directive were lowered, but not eliminated, with odds of 0.67 (95% confidence interval 0.65–0.69), 0.63 (0.61–0.65), and 0.47 (0.43–0.52) for residents with low, moderate and high health instability, respectively.ConclusionEven though both DNR and DNH orders are associated with serious health outcomes, DNH directives were not frequently used and often overturned. We suggest that policies recommending DNH directives be re-evaluated, with greater emphasis on advance care planning that better reflects resident values and wishes.

Dealing With Death Taboo: Discussion of Do-Not-Resuscitate Directives With Chinese Patients With Noncancer Life-Limiting Illnesses.

Noncancer patients with life-limiting diseases often receive more intensive level of care in their final days of life, with more cardiopulmonary resuscitation performed and less do-not-resuscitate (DNR) orders in place. Nevertheless, death is still often a taboo across Chinese culture, and ethnic disparities could negatively affect DNR directives completion rates. We aim to explore whether Chinese noncancer patients are willing to sign their own DNR directives in a palliative specialist clinic, under a multidisciplinary team approach. Retrospective chart review of all noncancer patients with life-limiting diseases referred to palliative specialist clinic at a tertiary hospital in Hong Kong over a 4-year period. Over the study period, a total of 566 noncancer patients were seen, 119 of them completed their own DNR directives. Patients had a mean age of 74.9. Top 3 diagnoses were chronic renal failure (37%), congestive heart failure (16%), and motor neuron disease (11%). Forty-two percent of patients signed their DNR directives at first clinic attendance. Most Chinese patients (76.5%) invited family caregivers at DNR decision-making, especially for female gender (84.4% vs 69.1%; P = .047) and older (age >75) age group (86.2% vs 66.7%; P = .012). Of the 40 deceased patients, median time from signed directives to death was 5 months. Vast majority (95%) had their DNR directives being honored. Health-care workers should be sensitive toward the cultural influence during advance care planning. Role of family for ethnic Chinese remains crucial and professionals should respect this family oriented decision-making.

Early and late do-not-resuscitate (DNR) decisions in patients with terminal COPD: a retrospective study in the last year of life

PurposeThe unpredictable trajectory of COPD can present challenges for patients when faced with a decision regarding a do-not-resuscitate (DNR) directive. The current retrospective analysis was conducted to investigate factors associated with an early DNR decision (prior to last hospital admission) and differences in care patterns between patients who made DNR directives early vs late.Patients and methodsElectronic health records (EHR) were reviewed from 271 patients with terminal COPD who died in a teaching hospital in Taiwan. Clinical parameters, patterns of DNR decisions, and medical utilization were obtained. Those patients who had a DNR directive earlier than their last (terminal) admission were defined as “Early DNR” (EDNR).ResultsA total of 234 (86.3%) patients died with a DNR directive, however only 30% were EDNR. EDNR was associated with increased age (OR=1.07; 95% CI: 1.02–1.12), increased ER visits (OR=1.22; 95% CI: 1.10–1.37), rapid decline in lung function (OR=3.42; 95% CI: 1.12–10.48), resting heart rate ≥100 (OR=3.02; 95% CI: 1.07–8.51), and right-sided heart failure (OR=2.38; 95% CI: 1.10–5.19). The median time period from a DNR directive to death was 68.5 days in EDNR patients and 5 days in “Late DNR” (LDNR) patients, respectively (P<0.001). EDNR patients died less frequently in the intensive care unit (P<0.001), received less frequent mechanical ventilation (MV; P<0.001), more frequent non-invasive MV (P=0.006), and had a shorter length of hospital stay (P=0.001).ConclusionsMost patients with terminal COPD had DNR directives, however only 30% of DNR decisions were made prior to their last (terminal) hospital admission. Further research using these predictive factors obtained from EHR systems is warranted in order to better understand the relationship between the timing associated with DNR directive decision making in patients with terminal COPD.

Factors Associated With the Do-Not-Resuscitate Decision Among Surrogates of Elderly Residents at a Nursing Home in Taiwan

Summary Background Do-not-resuscitate (DNR) in nursing homes is an emerging advance directive in Taiwan, but little research has been conducted. The purpose was to determine the factors associated with signing a DNR directive in the largest hospital affiliated nursing home in Taiwan. Methods A cross-sectional survey was conducted using a convenience sample from a nursing home in northern Taiwan between January 2011 and January 2012. The demographic characteristics of elderly residents were collected. 213 family surrogates of elderly residents were interviewed using a self-developed structured questionnaire related to DNR issues. The data were analyzed via descriptive statistics and logistic regression analysis. Results Only 24/213 (11.3%) of elderly residents had the DNR directives. Of these, 20/24 (83%) were made by family surrogates. The factors significantly associated with the DNR decision included the elderly residents had severe brain injury (OR: 8.83, p = 0.023), pulmonary disease (OR: 7.24, p = 0.004), cancer (OR: 5.20, p = 0.045); the family surrogates believe in Buddhism (OR: 8.02, p = 0.030), and ever having discussed DNR with the resident (OR: 19.23, p Conclusions The findings indicated the DNR decision was associated with residents' conditions and surrogates' factors. These information are helpful to medical personnel in nursing homes to better understand and to assist the DNR decision-making process.

Cultural perspectives of older nursing home residents regarding signing their own DNR directives in Eastern Taiwan: a qualitative pilot study.

BackgroundChinese tradition and culture developed from Taoism, Confucianism, and Buddhism and have influenced ethnic Chinese for thousands of years, particularly thoughts on death. Many ethnic Chinese, particularly older people, refrain from discussing death-related concerns, making it difficult to obtain advance directives, including do-not-resuscitate (DNR) directives, signed independently by older people. This study explored the attitudes of older nursing home residents in Taiwan toward signing their own DNR directives.MethodsThis study adopted purposive sampling and collected data through in-depth interviews. The data were analysed using qualitative inductive content analysis, and the study location was a nursing home in Eastern Taiwan.ResultsA total of 11participants were recruited from a sample of 12 eligible participants. Most of the older residents in this study refused to make decisions independently regarding DNR directives. Content analysis of the interviews revealed four themes concerning refusing to sign DNR directives independently: not going against nature, accepting the results of cause and effect, viewing the family as a decision-making system, and practising self-effacement. Chinese cultural aspects, including Taoist, Buddhist, and Confucian philosophy, affected the autonomy of the older residents, and they relied on others to make decisions for them.ConclusionsProfessionals must respect this family-oriented decision-making thinking of older residents because it reflects personal choice. Otherwise, healthcare providers may play a mediating role in coordinating and communicating between older residents and their families regarding EOL-care-related concerns, replacing the traditional practice of holding a family meeting.

Factors related to do-not-resuscitate directives among critically ill patients in a medical intensive care unit

Objective: This study was to clarify the prevalence of do-not-resuscitate (DNR) and identify the factors related to critically ill patients who have DNR directives or not in a medical Intensive Care Unit (ICU) in Taiwan. Materials and Methods: A retrospective chart review of 100 critically ill patients expired between January and December 2012 were included. The outcome was DNR or not when patient expired. Other variables regarding patient's demographics, disease-and DNR-related information were recorded. Logistic regression model was used to assess the related factor about DNR. A P Results: DNR rates were 87%, and the mean interval from DNR signature to death was 3.9 days. Compared with the patients without DNR signature, the patients with DNR signature had no statistical significance of cancer diagnosis (odds ratio [OR] = 3.41, 95% confidence interval [CI] = 0.88-13.25, P = 0.076), and frequency of ICU admission (OR = 4.17, 95% CI = 0.92-18.86, P = 0.063). In addition, there were 4.22-fold (95% CI = 0.90-19.89) but no statistical significance ( P = 0.068) of the frequency of ICU admission by patients with DNR directives compared to those without DNR directives after adjusting the variables of age, gender, economic status, primary diagnosis, and level of consciousness. Conclusion: Although this study indicated no statistical significance, we found that a patient with a cancer diagnosis and more frequency of ICU admissions tended to influence on family members concerning DNR directives in clinical setting. Early initiation of palliative care and DNR discussion may enhance the quality of care for dying patients.

Ethical Attitudes, Perceptions of DNR and Advance Directives of General Population

Purpose: This study was done to identify differences in awareness and ethical attitudes associated with Do-Not-Resuscitate (DNR) and decision about advance directives among the general populations. Methods: Participants were 193 ordinary people from 2 provinces and data were collected from December 23, 2013 to January 30, 2014. Structured questionnaires included awareness measuring tool and ethical attitudes measuring tool. Data were analyzed with descriptive analysis using descriptive statistics, t-test, and xtest with SPSS/WIN 18.0 program. Results: Most of the participants responded that they agreed on the necessity of DNR and needed to do it by guidelines, while 47.2% responded that patients and their families should make a decision about the DNR. After the decision about DNR, they also agreed that efforts should be made to give the best treatment even if a DNR decision had been made by the patient. In general, there was a significant difference in advance directives for CPR depending on gender and living with family or not. Conclusion: For a professional and systematic approach to the problem, DNR guidelines sufficient to elicit social consensus are needed.

Prevalence and Related Factors of Do-Not-Resuscitate Directives Among Nursing Home Residents in Taiwan

To report the prevalence of Do-Not-Resuscitate (DNR) directives and to explore the factors associated with the presence of DNR directives among nursing home residents in Taiwan. A cross-sectional, correlation study. Seven nursing homes in southern Taiwan. Nursing home residents and their family surrogates. Data were collected using chart abstraction and a questionnaire survey. We used multivariate logistic regression to analyze the associations between resident, family surrogate, and facility characteristics and the presence of DNR directives. Among the 201 nursing home residents, 33 (16.4%) had DNR directives and 91% of the directives had been put in place by family surrogates. Our data revealed that resident's age (OR = 1.06, 95% CI = 1.01-1.12), cognitive function score (OR = 0.91, 95% CI = 0.85-0.97), prior DNR discussion between physician and family surrogate (OR = 4.09, 95% CI = 1.53-10.96), and nursing home with DNR policy (OR = 17.71, 95% CI = 5.87-53.46) were independently and associated with the presence of a DNR directive. The prevalence of DNR directives among Taiwanese nursing home residents was lower than that in other countries. Our results point out the lack of DNR policy in most Taiwanese nursing homes and highlight the need for policy makers to implement further regulations. Meanwhile, education about advance directives is warranted to increase public and professional awareness and to facilitate empowerment of the increasing number of frail elderly nursing home residents in Taiwan.

Mood and Anxiety Symptoms among Advanced Cancer Patients: Kids Matter (720)

Objectives 1. Recognize that patients with metastatic spinal cord compression have limited life span. 2. Recognize that very low percentage of patients with metastatic spinal cord compression had advanced care plan in a tertiary cancer center. 3. Discuss the urgency to initiate an earnest and close dialogue between the treating physician and his patient. I. Background. End-of-life communication is crucial because most U.S. hospitals implement cardiopulmonary resuscitation (CPR) in the absence of do-not-resuscitate directives (DNRs). Metastatic spinal cord compression (MSCC) has a median survival time of 3e6 months; yet there is little DNR utilization data in this population. II. Research Objectives. The objective of this study was to determine DNR utilization patterns in cancer patients with MSCC. III. Methods. A retrospective database analysis (March 2003eJune 2008) of DNR data for 88 cancer patients who had MSCC and required rehabilitation consultation at M. D. Anderson Cancer Center (MDACC) was performed. IV. Results. The mean age of this patient population was 54-years-old (range 14e81). Thirty patients were female (33%), 20 patients (23%) had a living will, 27 patients (31%) had identified a healthcare proxy, and 5 patients (6%) had DNR directives. The median survival for these patients was 4.2 months. V. Conclusion. Even with strong evidence showing the median life span of MSCC patients is 3e6 months; it seems many patients are not aware of the urgency to have an advance directive. This may be an indicator of delayed end-of-life palliative care and suboptimal doctor-patient communication. Using this catastrophic event to trigger communication and initiate palliative care may be beneficial. VI. Implications for Research, Policy, or Practice. Clinicians can be better equipped with evidence on cancer patients’ prognosis and apply it when initiating end-of-life conversations with cancer patients.

How do-not-resuscitate orders are utilized in cancer patients: Timing relative to death and communication-training implications

End-of-life communication is crucial because most U.S. hospitals implement cardiopulmonary resuscitation (CPR) in the absence of do-not-resuscitate directives (DNRs). Despite this, there is little DNR utilization data to guide the design of communication-training programs. The objective of this study was to determine DNR utilization patterns and whether their use is increasing. A retrospective database analysis (2000-2005) of DNR data for 206,437 patients, the entire patient population at Memorial Sloan-Kettering Cancer Center (MSKCC), was performed. The hospital recorded, on average, 4,167 deaths/year. In 2005, 86% of inpatient deaths had a DNR, a 3% increase since 2000 (p < .01). For patients who died outside the institution (e.g., hospice), 52% had a DNR, a 24% increase over 6 years (p < .00001). Adult inpatients signed 53% of DNRs but 34% were signed by surrogates. The median time between signing and death was 0 days, that is, the day of death. Only 5.5% of inpatient deaths had previously signed an outpatient DNR. Here, the median time between signing and death was 30 days. Although DNR directives are commonly utilized and their use has increased significantly over the past 6 years, most cancer patients/surrogates sign the directives on the day of death. The proximity between signing and death may be a marker of delayed end-of-life palliative care and suboptimal doctor-patient communication. These data underscore the importance of communication-training research tailored to improve end-of-life decision making.

Cardiopulmonary resuscitation and do not resuscitate orders

In medical practice, the different scenarios in which cardio respiratory resuscitation (CPR) may be applied must be taken into account. CPR is crucial in subjects that arrive in emergency rooms or suffer a cardiac arrest in public places or at their homes. It is also critical in hospitalized patients with potentially reversible diseases, who suffer cardiac arrest as an unexpected event during their evolution. In intensive care units, the decision is particularly complex. The concepts of therapeutic proportionality, treatment futility and therapeutic tenacity can help physicians in their decision making about when CPR is technically and morally mandatory. The do not resuscitate (DNR) decision in taken when a patient is bearing an irreversible disease and his life is coming to an end. DNR decisions are clearly indicated in intensive care units to limit the therapeutic effort and in other hospital facilities, when death is foreseeable and therapeutic tenacity must be avoided. DNR orders must be renewed and reconsidered on a daily basis. It does not mean that other treatment should be discontinued and by no means should the patient be abandoned. DNR and previous directives, DNR and quality of life and DNR communication are also commented in the present article.

療養型病床群1施設における心肺蘇生および急性期病院への転院に関する家族の希望

Because long-term care facilities are being asked to care for more and more residents who are dying, the facilities require that new residents and families make decisions regarding their end-of-life care at the time of the admission process. An advance directive including "do-not resuscitate directives (DNR)" or "do-not-hospitalize directives (DNH)" is a written document that afford individuals the opportunity to determine the type and extent of end-of-life care when they are incapable of participation in medical decision making. It is expected that Japanese elderly and families make individual decisions regarding end-of-life care by a Japanese-style decision-making model including advance directives. The purpose of this study was to explore families' decision-making factors regarding cardiopulmonary resuscitate (CPR) and hospitalize orders in a long-term care hospital. We assessed 70 admissions in a long-term care hospital in Aichi prefecture from April 2005 to September 2006. All residents were divided into two groups according to their CPR or hospitalize order. Data on the admission characteristics of the residents were collected from medical charts. The prevalence of older age, functional dependence, and illness did not vary significantly with CPR or hospitalize order recorded by families, however, significant variation among physicians existed in the CPR and hospitalize orders. Wide variation in the likelihood of having CPR and hospitalize orders among physicians who explain an advance directive suggests a need for standardized methods for eliciting the end-of-life preferences of residents and families on admission to long-term care hospitals.

Which Clinical Indicators and Resident Characteristics Are Associated With Health Care Practitioner Nursing Home Visits or Hospital Transfer for Urinary Tract Infections?

(1) To determine factors associated with practitioner visitation and/or hospital transfer for skilled nursing facility (SNF) patients who develop a urinary tract infection (UTI) and (2) to determine if SNF patients with a Do Not Resuscitate (DNR) directive are less likely to be personally assessed and/or transferred to the hospital in the event of a UTI when compared to patients without a DNR directive. Retrospective cohort study using nursing home medical record review. Participants were 564 residents from 35 nursing homes in 3 states who became acutely ill with UTI during the first 90 days of their nursing home admission. They were identified from 2832 random nursing home Medicare admissions and divided into 2 groups, those with DNR directives (n = 334) and those without (n = 230). Logistic regression was used to determine factors associated with practitioner in-person assessment and/or hospitalization, and to determine differences in the likelihood of practitioner in-person assessment and/or hospitalization among those with DNR directives versus those without DNR directives. Only one third (29%) of patients with unstable vital signs were seen by a practitioner or transferred to a hospital. Factors associated with practitioner assessment or hospital transfer were elevated temperature (OR 1.7, CI 1.04-2.64), pulse more than 100 beats per minute (OR 1.7, CI 1.01-2.99), and delirium (OR 2.1, CI 1.267-3.44). White residents were less likely to be assessed by a practitioner or transferred to a hospital (OR 0.45, CI 0.22-0.95). DNR directives were not significantly associated with fewer in-person assessments (P = .067). Only one third of SNF patients who developed a UTI with unstable vital signs were personally assessed by a practitioner and/or hospitalized. Patients with delirium were twice as likely to be assessed or transferred to a hospital, suggesting that practitioners use delirium as an indicator of illness severity. However, practitioner visit or transfer was also associated with ethnic background. In the absence of good evidence regarding which nursing home residents are likely to benefit from hospitalization or an urgent practitioner visit, these care decisions will continue to be associated with factors that are unknown.

Do‐Not‐Resuscitate and Do‐Not‐Hospitalize Directives of Persons Admitted to Skilled Nursing Facilities Under the Medicare Benefit

To determine prevalence and factors associated with do-not-resuscitate (DNR) and do-not-hospitalize (DNH) directives of residents admitted under the Medicare benefit to a skilled nursing facility (SNF). To explore geographic variation in use of DNR and DNH orders. Retrospective cohort study. Nursing homes in the United States. Medicare admissions to SNFs in 2001 (n=1,962,742). Logistic regression was used to select factors associated with DNR and DNH directives and state variation in their use. Thirty-two percent of residents had DNR directives, whereas less than 2% had DNH directives. Factors associated with having a DNR or DNH directive at the resident level included older age, cognitive impairment, functional dependence, and Caucasian ethnicity. African-American, Hispanic, Asian, and North American Native residents were all significantly less likely than Caucasian residents to have DNR (adjusted odds ratio (OR)=0.35, 0.51, 0.61, and 0.62, respectively) or DNH (adjusted OR=0.26, 0.41, 0.43, and 0.67, respectively) directives. In contrast, residents in rural and government facilities were more likely to have DNR or DNH directives. After controlling for resident and facility characteristics, significant variation between states existed in the use of DNR and DNH directives. Ethnic minorities are less likely to have DNR and DNH directives even after controlling for disease status, demographic, facility, and geographic characteristics. Wide variation in the likelihood of having DNR and DNH directives between states suggests a need for better-standardized methods for eliciting the care preferences of residents admitted to SNFs under the Medicare benefit.

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

Whether or not physicians should conduct cardiopulmonary resuscitation (CPR) in terminal cancer patients has long been debated. We conducted this prospective observational study to characterize current CPR and do-not-resuscitate (DNR) practice among terminal cancer patients in South Korea. The study involved patients with terminal cancer who were admitted at the Seoul National University Boramae Hospital for supportive care only, and who died between January 1, 2003 and April 30, 2004. We investigated the practices relating to the DNR directive, i.e., how many days before death was the directive effective, and from whom was it obtained. Of the enrolled 165 patients, 97 were male with a mean age of 65. Median duration of admission to death was 24 days (range 7-207, mean 31.7). The DNR directive was implemented in 143 patients (86.7%). All discussions about DNR took place between physician and family members, except in only one case. DNR directives were enacted at a median of 8.0 days (range 0-79, mean 12.15) before death. For 18 patients, the DNR directive was formally taken on the day of admission. In contrast, 14 cases (9.8%) were agreed on the day of death, 18.8% within 48 h of death, and 46.8% (67 of 143) within 1 week before death, 62% before 10 days, and 71.3% within 2 weeks. The worse the performance status of the patient, the earlier the DNR discussion was issued. Also, the lower the economic and educational status of the family member, the earlier the DNR directive was attained. Of the 165 patients with terminal cancer, CPR was performed in 13 cases (7.9%): in seven cases (4.2%) CPR was requested by a family member, and in six cases arrest occurred before DNR discussion was issued. None of the resuscitated patients survived. In relation to DNR decisions in South Korean cancer patients, proxy decision-making is overwhelming and issuance of DNR discussion is raised at a late stage.

DNR directives are established early in mechanically ventilated intensive care unit patients

Setting treatment goals in the intensive care unit (ICU) often involves resuscitation decisions. Our objective was to study the rate of establishing do-not-resuscitate (DNR) directives, determinants, and outcomes of those directives for mechanically ventilated patients. In a multicentre observational study, we included consecutive adults with no DNR directives within 24 hr of ICU admission who were mechanically ventilated for at least 48 hr. We identified the rate with which DNR directives were established, and factors associated with these directives. Among 765 patients, DNR directives were established for 231 (30.2%) patients; 143 (62.1%) of these were established within the first week. Factors independently associated with a DNR directive were: patient age [> or = 75 yr (hazard ratio [HR] 2.3, 95% confidence interval 1.5-3.4], 65 to 74 yr (HR 1.8, 1.2-2.7), 50 to 64 yr (HR 1.4, 1.0-2.2) relative to < 50 yr); medical rather than surgical diagnosis (HR 1.8, 1.3-2.5); multiple organ dysfunction score (HR 1.7 for each five-point increment, 1.4-2.0); physician prediction of ICU survival [< 10% (HR 15.0, 6.7-33.6)], 10 to 40% [(HR 5.0, 2.3-11.2), 41 to 60% (HR 4.0, 1.8-9.0) relative to > 90%]; and physician perception of patient preference to limit life support (no advanced life support [(HR 5.8, 3.6-9.4) or partial advanced life support (HR 3.2, 2.2-4.6) compared to full measures]. One third of mechanically ventilated patients had DNR directives established early during their ICU stay after the first 24 hr of admission. The strongest predictors of DNR directives were physician prediction of low probability of survival, physician perception of patient preference to limit life support, organ dysfunction, medical diagnosis and age.

Resuscitation Policy Concerning Older Adults: Ethical Considerations of Paternalism Versus Autonomy

The heated national debate concerning health care must include a discussion of a patient's wishes and the implications of his or her right to determine individual medical treatment decisions, especially at the end of life. This article is an examination of physician paternalism versus patient autonomy concerning do-not-resuscitate (DNR) orders within the context of utilitarian ethical theory. The author proposes effective compromise between the two; consideration of decision making on a case-by-case basis; enhanced education for all actors concerning cardiopulminary resucitation (CPR), DNR, and advanced directives; and consensus reached through democratic debate regarding the allocation of health care resources.