Race Does Not Influence Do-Not-Resuscitate Status or the Number or Timing of End-of-Life Care Discussions at a Pediatric Oncology Referral Center
Justin N. BakerN. SheshWei LiuKumar SrivastavaJavier R. KaneChristine A. ZawistowskiElizabeth BurghenJami S. GattusoNancy K. WestJennifer AlthoffAdam FunkPamela S. Hinds
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Background: End-of-life care (EOLC) discussions and decisions are common in pediatric oncology. Interracial differences have been identified in adult EOLC preferences, but the relation of race to EOLC in pediatric oncology has not been reported. We assessed whether race (white, black) was associated with the frequency of do-not-resuscitate (DNR) orders, the number and timing of EOLC discussions, or the timing of EOLC decisions among patients treated at our institution who died. Methods: We reviewed the records of 380 patients who died between July 1, 2001 and February 28, 2005. χ2 and Wilcoxon rank-sum tests were used to test the association of race with the number and timing of EOLC discussions, the number of DNR changes, the timing of EOLC decisions (i.e., DNR order, hospice referral), and the presence of a DNR order at the time of death. These analyses were limited to the 345 patients who selfidentified as black or white. Results: We found no association between race and DNR status at the time of death (p = 0.57), the proportion of patients with DNR order changes (p = 0.82), the median time from DNR order to death (p = 0.51), the time from first EOLC discussion to DNR order (p = 0.12), the time from first EOLC discussion to death (p = 0.33), the proportion of patients who enrolled in hospice (p = 0.64), the time from hospice enrollment to death (p = 0.2) or the number of EOLC discussions before a DNR decision (p = 0.48). Conclusion: When equal access to specialized pediatric cancer care is provided, race is not a significant factor in the presence or timing of a DNR order, enrollment in or timing of enrollment in hospice, or the number or timing of EOLC discussions before death.Keywords:
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The decision to sign a do-not-resuscitate (DNR) consent is critical for patients concerned about their end-of-life medical care. Taiwan's National Health Insurance Administration (NHIA) introduced a family palliative care consultation fee to encourage family palliative care consultations; since its implementation, identifying which families require such consultations has become more important. In this study, the Taiwanese version of the Palliative Care Screening Tool (TW-PCST) was used to determine each patient's degree of need for a family palliative care consultation.This study analyzed factors associated with signing DNR consents. The results may inform family palliative care consultations for families in need, thereby achieving a higher DNR consent rate and promoting the effective use of medical resources, including time, labor, and funding.In this retrospective study, logistic regression analysis was conducted to determine which factors affected the DNR decisions of 2144 deceased patients (aged ≥ 20 years), whose records were collected from the Taipei City Hospital health information system from 1 January to 31 December 2018.Among the 1730 patients with a DNR consent, 1298 (75.03%) received family palliative care consultations. The correlation between DNR consent and family palliative care consultations was statistically significant (p < 0.001). Through logistic regression analysis, we determined that participation in family palliative care consultation, TW-PCST score, type of ward, and length of stay were significant variables associated with DNR consent.This study determined that TW-PCST scores can be used as a measurement standard for the early identification of patients requiring family palliative care consultations. Family palliative care consultations provide opportunities for patients' family members to participate in discussions about end-of-life care and DNR consent and provide patients and their families with accurate medical information regarding the end-of-life care decision-making process. The present results can serve as a reference to increase the proportion of patients willing to sign DNR consents and reduce the provision of ineffective life-prolonging medical treatment.
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Use of health care resources by individuals at the end of life (EOL) varies widely across the United States (1).Whereas individual patients who participate in advance care planning tend to have lower rates of in-hospital death and higher rates of hospice use (2), scant information in national databases regarding patient advance directives has led to knowledge gaps regarding the associations between hospital use of advance directives and EOL healthcare use.We leveraged new International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) (3) identifiers of patient "do-not-resuscitate" (DNR) status to characterize national variation in acute care hospital DNR orders-a common method of documenting directives for treatment limitation-across the United States, and correlated hospital DNR rates with measures of EOL healthcare use. MethodsWe used the Hospital Cost and Utilization Project, National Inpatient Sample (NIS), a representative sample of hospitalized patients in the United States during 2011 and 2012 (4).During 2011, the NIS was a 20% stratified probability sample of nonfederal acute-care hospitals, with hospital identifiers allowing linkage to the Dartmouth Atlas of Healthcare measures of hospital EOL healthcare use (http://www.dartmouthatlas.org/tools/downloads.aspx?tab=40).During 2012, the NIS eliminated hospital identifiers, but used a 20% sample of patients from nonfederal acute-care hospitals across the United States, allowing improved characterization of variation across U.S. hospitals.We used ICD-9-Clinical Modification code V49.86 (introduced October 1, 2010) to identify patient DNR status, and conducted survey-weighted analyses to identify population estimates of hospital DNR rates.Analyses included cases 65 years old or older at each U.S. hospital, excluding patients admitted to hospitals with 0 DNR orders (5%).We calculated risk-standardized hospital DNR rates for 2011 and 2012 from multivariable hierarchical logistic regression models adjusted for patient demographics, 235 Clinical Classification Codes characterizing principal reason for hospitalization, comorbidities (5), acute organ failures (6), and hospital characteristics.We summarized hospital variation in DNR orders using the median odds ratio (7), a measure of the median odds of DNR status for similar patients selected from among all possible pairs of hospitals.We abstracted a priori 12 measures of hospital EOL healthcare utilization from the Dartmouth Atlas that correspond to proposed measures of quality care at EOL (8), and used linear regression to evaluate
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Articles| March 01 1993 'Do not resuscitate' orders and end-of-life care planning C Marsden C Marsden Search for other works by this author on: This Site PubMed Google Scholar Am J Crit Care (1993) 2 (2): 177–179. https://doi.org/10.4037/ajcc1993.2.2.177 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Cite Icon Cite Get Permissions Citation C Marsden; 'Do not resuscitate' orders and end-of-life care planning. Am J Crit Care 1 March 1993; 2 (2): 177–179. doi: https://doi.org/10.4037/ajcc1993.2.2.177 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAmerican Journal of Critical Care Search Advanced Search You do not currently have access to this content.
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We found that DNR orders were always signed late.Cancer patients who signed DNR orders beyond 3 days before death were less likely to undergo aggressive procedures but more likely to be given comfort measures, compared with those within 3 days.Further studies are necessary to better understand the optimum timing and promote early DNR orders in advanced cancer patients. Timing of do-not-resuscitate order and aggressiveness of care near the end of life in cancer patients: a retrospective cohort studyA retrospective chart review was done in three tertiary hospitals in China.Data about cancer patients' characteristics, DNR order, aggressive and comfort measures were collected during the last hospitalization since January 2016 to December 2017. Measurement.A data extraction form was developed by the research team according to the framework of the research (Figure 1).It was composed of:(1) Timing of DNR orders;(2) Health care utilization (comfort measures and life-sustaining treatments (LSTs)).
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There has been considerable criticism recently over the use of end-of-life pathways and do-not-resuscitate orders with vulnerable, incapable patients, often without discussion. This criticism has led to press and judicial scrutiny of the lawfulness of decisions to withdraw or withhold life-sustaining treatment. In this article, the author reviews the law and argues that flawed decision-making by doctors and nurses, rather than the actual end-of-life pathway or do-not-resuscitate order, is where the lawfulness of withdrawing and withholding treatment must be challenged.
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BACKGROUND Medical emergency teams frequently implement do not resuscitate orders, but little is known about end‐of‐life care in this population. OBJECTIVE To examine resource utilization and end‐of‐life care following medical emergency team‐implemented do not resuscitate orders. DESIGN Retrospective review. SETTING Single, tertiary care center. PATIENTS Consecutive adult inpatients requiring a medical emergency team activation over 1 year. MEASUREMENTS Changes to code status, time spent on medical emergency team activations, frequency of palliative care consultation, discharges with hospice care. INTERVENTIONS None. RESULTS We observed 1156 medical emergency team activations in 998 patients. Five percent (58/1156) resulted in do not resuscitate orders. The median time spent on activations with a change in code status was longer than activations without a change (66 vs 60 minutes, P = 0.05). Patients with a medical emergency team‐implemented do not resuscitate order had a higher inpatient mortality (43 vs 27%, P = 0.04) and were less likely to be discharged with hospice at the end of life than patients with a preexisting do not resuscitate order (4 vs 29%, P = 0.01). There was no difference in palliative care consultation in patients with a preexisting do not resuscitate versus medical emergency team‐implemented do not resuscitate order (20% vs 12%, P = 0.39). CONCLUSIONS Despite high mortality, patients with medical emergency team‐implemented do not resuscitate orders had a relatively low utilization of end‐of‐life resources, including palliative care consultation and home hospice services. Coordinated care between medical emergency teams and inpatient palliative care services may help to improve end‐of‐life care. Journal of Hospital Medicine 2014;9:372–378. © 2014 Society of Hospital Medicine
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Background: There are multiple factors that may cause end-of-life conflict in the critical care setting. These include severe illness, family distress, lack of awareness about a patient’s wishes, prognostic uncertainty, and the participation of multiple providers in goals-of-care discussions. Methods: Case report and discussion of the associated ethical issues. Results: We present a case of a patient with a pontine stroke, in which the family struggled with decision-making about goals-of-care, leading to fluctuation in code status from Full Code to Do Not Resuscitate-Comfort Care, then back to Full Code, and finally to Do Not Resuscitate-Do Not Intubate. We discuss factors that contributed to this situation and methods to avoid conflict. Additionally, we review the effects of discord at the end-of-life on patients, families, and the healthcare team. Conclusion: It is imperative that healthcare teams proactively collaborate with families to minimize end-of-life conflict by emphasizing decision-making that prioritizes the best interest and autonomy of the patient.
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BackgroundEnd-of-life 照顾不通常是在心病学部门的优先级。我们寻求了在 do-not-resuscitate (DNR ) 的介绍以后在 end-of-life 照顾评估变化顺序 protocol.Methods &；在在二经期的一个心病学部门的所有死亡的 ResultsRetrospective 分析，在协议的介绍前后。人口统计的特征， DNR 订单的使用，和 end-of-life 照顾的比较在两个时期之间发出，根据在表(组 A ) ，一份常规 DNR 订单(组 B ) 或任何 DNR 的缺席订的新 DNR 的第二经期(组 C ) 的存在。死亡的数字在两个时期是类似的(n = 198 对 n = 197 ) 。与一份 DNR 订单死的病人的率显著地增加了(57.1% 对 68.5% ；P = 0.02 ) 。仅仅在两个时期的 4% 病人知道关于心肺的复活作的决定。在组 A 的病人更早收到了 DNR 顺序一天，并且 24.5% 在录取的开始的 24 h 以内收到了它(对 2.6% 在第一个时期；P <；0.001 ) 。在有一个可植入的 cardioverter 使用高压脉冲来消减心脏(ICD ) 的组 A 的所有病人把电震疗法撤销(对 25.0% 在第一个时期；P = 0.02 ) 一个 DNR 顺序协议的 .ConclusionsThe 介绍可以由增加使用并且弄短在心脏病患者改进 end-of-life 照顾 DNR 订单的登记的时间。它可以也在地方与这些订单在病人贡献增加 ICD 释放。然而，在疾病的迟了的阶段的表的介绍没能改进耐心的参予。
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