Factors influencing terminal cancer patients’ autonomous DNR decision: a longitudinal statutory document and clinical database study

Abstract

Objective Much of our knowledge of patient autonomy of DNR (do-not-resuscitate) is derived from the cross-sectional questionnaire surveys. Using signatures on statutory documents and medical records, we analyzed longitudinal data to understand the fact of terminal cancer patients’ autonomous DNR decision-making in Taiwan. Methods Using the medical information system database of one public medical center in Taiwan, we identified hospitalized cancer patients who died between Jan. 2017 and Dec. 2018, collected their demographic and clinical course data and records of their statutory DNR document types, letter of intent (DNR-LOI) signed by the patient personally and the consent form signed by their close relatives. Results We identified 1,338 signed DNR documents, 754 (56.35%) being DNR-LOI. Many patients had the first DNR order within their last week of life (40.81%). Signing the DNR-LOI was positively associated with being under the care of a family medicine physician prior to death at last hospitalization and having hospice palliative care and negatively associated with patient age ≥ 65 years, no formal education, having ≥ 3 children, having the first DNR order to death ≤ 29 days, and the last admission in an intensive care unit. Conclusions A substantial proportion of terminal cancer patients did not sign DNR documents by themselves. It indicates they may not know their actual terminal conditions and lose the last chance to grasp time to express their life values and wishes. Medical staff involving cancer patient care may need further education on the legal and ethical issues revolving around patient autonomy and training on communicating end-of-life options with the patients. We suggest proactively discussing DNR decision issues with terminal cancer patients no later than when their estimated survival is close to 1 month.

Factors affecting do-not-attempt-resuscitation (DNAR) decisions among adult patients in the emergency department of a general tertiary teaching hospital in China: a retrospective observational study

“…Additionally, certain patients’ families requested that the patient’s condition remain confidential, a determination typically made in consultation between the family and attending physicians 52. When signing a DNAR decision for a patient with cancer, factors such as the chance of recovery of autonomic circulation, acceptable neurological outcomes after CPR, and the wishes of the patient and his family are taken into account 53…”

“… 52 When signing a DNAR decision for a patient with cancer, factors such as the chance of recovery of autonomic circulation, acceptable neurological outcomes after CPR, and the wishes of the patient and his family are taken into account. 53 …”

Do not attempt cardiopulmonary resuscitation decision-making process: scoping review

“…27 More broadly, Abe et al, 28 Becker et al 29 and Choi et al 30 identify DNACPR decisions within the hospitalisation period, while Abe et al 28 identified 9.2% of discussions as occurring during an outpatient visit. Typically, end-of-life issues were identified as being discussed prior to becoming severely ill, 31 being informed of a poor prognosis and/or referred for palliative care, 32 having 4-6 months to live, 33 disease progressed to terminal stage, 34 last week of life, 35 health deteriorated, [36][37][38][39] person moving to a residential setting, 39 at a care plan meeting 39 and inpatient discharge. 38 Physicians have a direct influence on the timing of DNACPR discussions, 33 and the ideal timing of a DNACPR discussion may differ between patients.…”

“…41 Patients who were cared for by a family medical physician prior to death at last hospitalisation and those who had received hospice palliative care were more likely to have signed a DNACPR letter of intent. 35 Getting to know the patient and developing a rapport are crucial factors in feeling confident to have the DNACPR conversation. 49 Doctors acknowledged the need to involve patients and/or those close to the patient in resuscitation decisions, but there were occasions when this did not occur.…”

Knowledge gaps, attitudes, and practices regarding end-of-life medical care among physicians in an academic medical center

“…Patient education about ELMC options and CPR efficacy will play a critical role in reaching an acceptable consensus regarding ELMC. Likewise, medical employees also require additional training on communicating end-of-life options with the patients [6,8,9]. Furthermore, in the era of personalized medicine, the care provider-patient relationship has changed from medical paternalism to an autonomy-based relationship, in which patient participation in decision-making is an obligation rather than an opportunity [10].…”