The timing of do-not-resuscitate orders and hospital costs.
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. (+info)
A staff dialogue on do not resuscitate orders: psychosocial issues faced by patients, their families, and caregivers.
Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at Massachusetts General Hospital (MGH), founded The Kenneth B. Schwartz Center at MGH. The Schwartz Center is a non-profit organization dedicated to supporting and advancing compassionate health care delivery which provides hope to the patient, support to caregivers, and encourages the healing process. The Center sponsors the Schwartz Center Rounds, a monthly multidisciplinary forum where caregivers reflect on important psychosocial issues faced by patients, their families, and their caregivers, and gain insight and support from fellow staff members. The following case of a woman who developed lymphoma was discussed at the July and August, 1997 Schwartz Center Rounds. There were considerable delays and uncertainties in the diagnosis, which was followed by an unpredictably chaotic clinical course. Although she had made it clear to her doctor that she did not want "heroic measures," she had unexpectedly rallied so many times that her son and her husband wanted her doctors to do everything possible to keep her alive, including the performance of cardiopulmonary resuscitation (CPR). The clinical benefit of CPR in the event of cardiac arrest in those with cancer is discussed, as are do not resuscitate (DNR) orders, living wills, and healthcare proxies. In addition, the issues that surround DNR status, including who should discuss DNR status with a patient, and how and when it should be discussed, are reviewed. Staff raised concerns about the effect of discussing DNR status on the doctor-patient relationship, and wondered whether writing DNR orders adversely affect the care of patients. (+info)
The status of the do-not-resuscitate order in Chinese clinical trial patients in a cancer centre.
OBJECTIVE: To report and analyse the pattern of end-of-life decision making for terminal Chinese cancer patients. DESIGN: Retrospective descriptive study. SETTING: A cancer clinical trials unit in a large teaching hospital. PATIENTS: From April 1992 to August 1997, 177 consecutive deaths of cancer clinical trial patients were studied. MAIN MEASUREMENT: Basic demographic data, patient status at the time of signing a DNR consent, or at the moment of returning home to die are documented, and circumstances surrounding these events evaluated. RESULTS: DNR orders were written for 64.4% of patients. Patients in pain (odds ratio 0.45, 95% CI 0.22-0.89), especially if requiring opioid analgesia (odds ratio 0.40, 95% CI 0.21-0.77), were factors associated with a higher probability of such an order. Thirty-five patients were taken home to die, a more likely occurrence if the patient was over 75 years (odds ratio 0.12, 95% CI 0.04-0.34), had children (odds ratio 0.14, 95% CI 0.02-0.79), had Taiwanese as a first language (odds ratio 6.74, 95% CI 3.04-14.93), or was unable to intake orally (odds ratio 2.73, 95% CI 1.26-5.92). CPR was performed in 30 patients, none survived to discharge. CONCLUSIONS: DNR orders are instituted in a large proportion of dying Chinese cancer patients in a cancer centre, however, the order is seldom signed by the patient personally. This study also illustrates that as many as 20% of dying patients are taken home to die, in accordance with local custom. (+info)
Response of paramedics to terminally ill patients with cardiac arrest: an ethical dilemma.
BACKGROUND: In an environment characterized by cuts to health care, hospital closures, increasing reliance on home care and an aging population, more terminally ill patients are choosing to die at home. The authors sought to determine the care received by these patients when paramedics were summoned by a 911 call and to document whether do-not-resuscitate (DNR) requests influenced the care given. METHODS: The records of a large urban emergency medical services system were reviewed to identify consecutive patients with cardiac arrest over the 10-month period November 1996 to August 1997. Data were abstracted from paramedics' ambulance call reports according to a standardized template. The proportion of these patients described as having a terminal illness was determined, as was the proportion of terminally ill patients with a DNR request. The resuscitative efforts of paramedics were compared for patients with and without a DNR request. RESULTS: Of the 1534 cardiac arrests, 144 (9.4%) involved patients described as having a terminal illness. The mean age of the patients was 72.2 (standard deviation 14.8) years. Paramedics encountered a DNR request in 90 (62.5%) of these cases. Current regulations governing paramedic practice were not followed in 34 (23.6%) of the cases. There was no difference in the likelihood that cardiopulmonary resuscitation (CPR) would be initiated between patients with and those without a DNR request (73% v. 83%; p = 0.17). In patients for whom CPR was initiated, paramedics were much more likely to withhold full advanced cardiac life support if there was a DNR request than if there was not (22% v. 68%; p < 0.001). INTERPRETATION: Paramedics are frequently called to attend terminally ill patients with cardiac arrest. Current regulations are a source of conflict between the paramedic's duty to treat and the patient's right to limit resuscitative efforts at the time of death. (+info)
CPR or DNR? End-of-life decision making on a family practice teaching ward.
OBJECTIVE: To determine the proportion of patients on a family practice ward who had "code status" orders and end-of-life discussions documented on their charts in the first week of admission. To examine the correlation between a tool predicting the likelihood of benefit from cardiopulmonary resuscitation (CPR) and actual end-of-life decisions made by family physicians and their patients. DESIGN: Cross-sectional descriptive study using a retrospective chart review. SETTING: A 14-bed teaching ward where family physicians admit and manage their own patients in an urban tertiary care teaching hospital. PARTICIPANTS: Patients admitted to the ward for 7 or more days between December 1, 1995, and August 31, 1996. MAIN OUTCOME MEASURES: Frequency of documented "do not resuscitate" (DNR) or "full code" orders and documented end-of-life discussions. Prognosis-after-resuscitation (PAR) score. RESULTS: In the 103 charts reviewed, code status orders were entered within 7 days for 60 patients (58%); 31 were DNR, and 29 were full code. Discussion of code status was documented in 25% of charts. The PAR score for 40% of patients was higher than 5, indicating they were unlikely to survive to discharge from hospital should they require CPR. There was a significant association between PAR scores done retrospectively and actual code status decisions made by attending family physicians (P < .005). CONCLUSIONS: End-of-life discussions and decisions were not fully documented in patients' charts, even though patients were being cared for in hospital by their family physicians. A PAR score obtained during the first week of admission could assist physicians in discussing end-of-life orders with their patients. (+info)
A physician's guide to talking about end-of-life care.
A large majority of patients and close family members are interested in discussing end-of-life issues with their physician. Most expect their physician to initiate such dialogue. End-of-life discussions, however, must go beyond the narrow focus of resuscitation. Instead, such discussions should address the broad array of concerns shared by most dying patients and families: fears about dying, understanding prognosis, achieving important end-of-life goals, and attending to physical needs. Good communication can facilitate the development of a comprehensive treatment plan that is medically sound and concordant with the patient's wishes and values. This paper presents a practical 4-step approach to conducting end-of-life discussions with patients and their families: (1) Initiating Discussion, (2) Clarifying Prognosis, (3) Identifying End-of-Life Goals, and (4) Developing a Treatment Plan. By following these 4 steps, communication can be enhanced, fears allayed, pain and suffering minimized, and most end-of-life issues resolved comfortably, without conflict. (+info)
Treatment of acute myocardial infarction and 30-day mortality among women and men.
BACKGROUND: Previous studies have suggested that women with acute myocardial infarction receive less aggressive therapy than men. We used data from the Cooperative Cardiovascular Project to determine whether women and men who were ideal candidates for therapy after acute myocardial infarction were treated differently. METHODS: Information was abstracted from the charts of 138,956 Medicare beneficiaries (49 percent of them women) who had an acute myocardial infarction in 1994 or 1995. Multivariate analysis was used to assess differences between women and men in the medications administered, the procedures used, the assignment of do-not-resuscitate status, and 30-day mortality. RESULTS: Among ideal candidates for therapy, women in all age groups were less likely to undergo diagnostic catheterization than men. The difference was especially pronounced among older women; for a woman 85 years of age or older, the adjusted relative risk was 0.75 (95 percent confidence interval, 0.68 to 0.83). Women were somewhat less likely than men to receive thrombolytic therapy within 60 minutes (adjusted relative risk, 0.93; 95 percent confidence interval, 0.90 to 0.96) or to receive aspirin within 24 hours after arrival at the hospital (adjusted relative risk, 0.96; 95 percent confidence interval, 0.95 to 0.97), but they were equally likely to receive beta-blockers (adjusted relative risk, 0.99; 95 percent confidence interval, 0.95 to 1.03) and somewhat more likely to receive angiotensin-converting-enzyme inhibitors (adjusted relative risk, 1.05; 95 percent confidence interval, 1.02 to 1.08). Women were more likely than men to have a do-not-resuscitate order in their records (adjusted relative risk, 1.26; 95 percent confidence interval, 1.22 to 1.29). After adjustment, women and men had similar 30-day mortality rates (hazard ratio, 1.02; 95 percent confidence interval, 0.99 to 1.04). CONCLUSIONS: As compared with men, women receive somewhat less aggressive treatment during the early management of acute myocardial infarction. However, many of these differences are small, and there is no apparent effect on early mortality. (+info)
Withholding and withdrawing life-sustaining treatment.
Withholding or withdrawing life-sustaining therapies is ethical and medically appropriate in some circumstances. This article summarizes the American Medical Association's Education for Physicians on End-of-life Care (EPEC) curriculum module on withholding or withdrawing therapy. Before reviewing specific treatment preferences, it is useful to ask patients about their understanding of the illness and to discuss their values and general goals of care. Family physicians should feel free to provide specific advice to patients and families struggling with these decisions. Patients with decision-making capacity can opt to forego any medical intervention, including artificial nutrition/hydration and cardiopulmonary resuscitation. (+info)