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

Palliat Support Care. 2008 Dec;6(4):341-8. doi: 10.1017/S1478951508000540.


Objectives: 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.

Methods: 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.

Results: 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.

Significance of results: 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.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Advance Directives / psychology
  • Advance Directives / statistics & numerical data*
  • Aged
  • Aged, 80 and over
  • Attitude to Death
  • Communication
  • Decision Making*
  • Female
  • Hospices
  • Humans
  • Inpatients / psychology
  • Inpatients / statistics & numerical data*
  • Male
  • Middle Aged
  • Patient Participation / psychology
  • Patient Participation / statistics & numerical data*
  • Professional-Family Relations
  • Proxy / psychology
  • Proxy / statistics & numerical data*
  • Resuscitation Orders
  • Retrospective Studies
  • Social Support
  • Terminally Ill / psychology
  • Terminally Ill / statistics & numerical data*
  • United States / epidemiology