Search Results (23)

Background: “Do Not Resuscitate” (DNR) status has been implicated as an independent risk factor for mortality in patients admitted to the ICU. The implications of DNR status in older, critically ill patients for whom these conversations are often most relevant are less known. Objective: To determine the relationship between code status and mortality in a subset of critically ill, older ICU patients. Methods: Retrospective cohort study of critically ill older adults as defined by an APACHE II score ≥20 and age ≥70, admitted to the ICU at a large community hospital in Ontario from 1 January 2013 to 31 December 2018. Results: Of 613 patients admitted to the ICU, 163 met the inclusion criteria. Of these, 64 (39.3%) had a DNR order, while the remaining 99 (60.7%) did not and were considered full code. We found a strong association between DNR status and mortality (OR 2.61; 95% CI 1.33 to 5.09). Patients with a DNR order stayed fewer days in the ICU (7.7 days (±3.6) vs. 9.9 days (±8.3)) and used fewer resources than similarly ill patients who were full code with no difference in discharge morbidity. Patients with a DNR order had lower average costs of hospital and ICU admissions in comparison to patients who were full code (CAD 49,589.10/pt. vs. CAD 59,704.70/pt. (Canadian dollars)). Conclusions: Among critically ill, older ICU patients, DNR status is strongly associated with in-hospital mortality. Those in the full code group used more resources, resulting in higher costs of hospitalization without any difference in discharge morbidity. Full article

Background: The Act on Life-Sustaining Treatment (LST) for patients at the end of life (the Korean LST Decision Act), implemented in the Republic of Korea in February 2018, has led to changes in the end-of-life decision-making (EOLDM) process in children. This study aimed to investigate changes in pediatric EOLDM process and LST practices since the Korean LST Decision Act. Methods: This retrospective cohort study included 107 patients who died at Kyungpook National University Children’s Hospital from January 2015 to December 2020. Patients were divided into two groups: pre-law (January 2015–January 2018, n = 55) and post-law (February 2018–December 2020, n = 52). We analyzed medical records for EOLDM process, patient characteristics, intensive care unit (ICU) admission, documentation types, and LST withholding or withdrawal decisions. Results: After the Korean LST Decision Act, the median total hospitalization duration decreased significantly (14 days [IQR, 3–80] vs. 6 days [IQR, 2–18], p = 0.020), as did the median ICU length of stay (3 days [IQR 1–33] vs. 2.5 days [IQR 1–10.3], p = 0.002). The time from admission to end-of-life decision documentation was significantly shorter in group 2 (6 days [IQR 1–31] vs. 4 days [IQR 1–9], p = 0.027). The use of physician orders for life-sustaining treatment (POLST) documents increased (0% to 33.3%), while do-not-resuscitate (DNR) orders decreased (85.3% to 16.7%). Notably, LST withdrawal decisions increased from 0% to 27.8% (p = 0.001) in the post-legislation period. Conclusions: The Korean LST Decisions Act has led to significant changes in the EOLDM process for terminally ill children, including earlier decision-making, increased use of POLST documents, more frequent LST withdrawal decisions, and shorter hospital and ICU stays. These findings suggest a shift towards more structured and timely end-of-life care discussions in pediatric settings. Full article

Cardiopulmonary resuscitation (CPR) outcomes vary for patients with cancer. Here, we characterized cancer patients who underwent CPR in the emergency department (ED), their outcomes, and the effects of advanced care planning (ACP). The hospital databases and electronic medical records of cancer patients at a comprehensive cancer center who underwent CPR in the ED from 6 March 2016 to 31 December 2022 were reviewed for patient characteristics, return of spontaneous circulation (ROSC), conversion to do-not-resuscitate (DNR) status afterward, hospital and intensive care unit (ICU) length of stay, mortality, cost of hospitalization, and prior GOC discussions. CPR occurred in 0.05% of all ED visits. Of the 100 included patients, 67 patients achieved ROSC, with 15% surviving to hospital discharge. The median survival was 26 h, and the 30-day mortality rate was 89%. Patients with and without prior ACP had no significant differences in demographics, metastatic involvement, achievement of ROSC, or in-hospital mortality, but patients with ACP were more likely to change their code status to DNR and had shorter stays in the ICU or hospital. In conclusion, few cancer patients undergo CPR in the ED. Whether this results from an increase in terminally ill patients choosing DNR status requires further study. ACP was associated with increased conversion to DNR after resuscitation and decreased hospital or ICU stays without an increase in overall mortality. Full article

The increasing elderly population is driving higher utilization rates of long-term care facilities, where residents often have multiple chronic diseases, making them potential candidates for palliative care. Timely palliative care interventions can improve their quality of life and medical autonomy. This study systematically reviews the effectiveness of palliative care programs in long-term care facilities. Databases such as PubMed, EMBASE, Cochrane Library, and Airiti Library were searched up to 31 December 2023, using PICO criteria and the following keywords: ‘care home’, ‘nursing home’, ‘residential aged care facility’, and ‘long-term care facility’ for patients; and ‘Gold Standard Framework in Care Homes’, ‘integrated care pathway’, ‘care home project’, and ‘palliative care program’ for interventions. Seven articles were included. The results indicate that the Program of All-Inclusive Care for the Elderly (PACE) intervention did not significantly influence overall quality of life but did improve the quality of death. There were no statistical differences in comfort or quality of death between the dementia and non-dementia groups. However, PACE significantly reduced healthcare costs. The implementation of the Liverpool Care Pathway (LCP) notably enhanced the control of terminal symptoms, while the Gold Standard Framework in Care Homes (GSFCH) effectively improved end-of-life care rates, do-not-resuscitate (DNR) signing rates, advance care planning (ACP) completion rates, and reduced inappropriate readmission rates. While palliative care interventions are shown to improve the quality of end-of-life care, their practical application should be adapted to fit the implementation conditions and capabilities of domestic long-term care facilities. Full article

Aim. With the advent of an aging society and the development of end-of-life care, there is an increasing need to understand the older generation’s attitude toward end-of-life resuscitation. The study aimed to develop and validate a novel attitude scale toward end-of-life resuscitation in older inpatients. Method. Instrumental development and a psychometric evaluation were used. First, a new attitude scale toward end-of-life resuscitation was formulated from literature views, expert content validity, and face validity. Next, the new scale was evaluated using a principal component analysis and internal consistency reliability in a sample from 106 medical–surgical inpatients in a southern Taiwan hospital 1 enrolled through convenience sampling. Serving as an indicator of concurrent validity, a logistic regression analysis was performed to analyze the association between scores on the scale and intention to discuss end-of-life CPR issues. Results: After being validated by the expert content validity and face validity, a draft of a 20-item scale was created. Throughout the exploratory factor analysis, two items with low factor loadings were removed from the draft scale and an 18-item scale of attitude was generated. This 18-item scale had a three-factor structure that accounted for 64.1% of the total variance; the three components were named ‘stress, avoidance, and ignorance’, ‘a peaceful death’, and ‘self-determination and ambivalence’. The Cronbach’s alpha of the total scale and three components were 0.845, 0.885, 0.879, and 0.857, respectively, which indicated a favorable reliability. Scores on the scale were significantly associated with the intention to discuss end-of-life CPR issues, which also indicated a favorable concurrent validity. Conclusions: A 18-item attitude scale with three factors is a valid scale to measure the attitude toward end-of-life resuscitation. The result provides preliminary evidence of the psychometric properties of the scale. Further research with larger samples or other populations is required. Full article

Objectives: In the event of cardiac arrest, cardiopulmonary resuscitation (CPR) is an emergency procedure used to maintain the heart and lungs functional simultaneously. The do-not-resuscitate (DNR) order prohibits CPR and is therefore legally required. Despite this, a DNR remains a delicate and contentious issue that places physicians in morally ambiguous situations. This study aimed to assess Saudi citizens’ understanding of DNR orders, prior exposure to them, and preferences for DNR conversations. Methods: This was an online cross-sectional study that was conducted between January and April 2023 and aimed to assess the knowledge regarding DNR orders among Saudi populations. This study adapted a previously developed questionnaire tool by Al Ahmadi et al., which examined the knowledge and attitude toward do-not-resuscitate among patients and their relatives visiting outpatient clinics. Binary logistic regression analysis was the mean knowledge score for the study participants. Results: A total of 920 participants were involved in this study. Almost half of the study participants (49.6%) reported that they had heard of DNR before. The most commonly reported source of their information on DNR was healthcare providers (58.2%). The mean knowledge score of the study participants was 1.9 (1.3) out of 6, which is equal to 31.7% of the total maximum score. This demonstrates the weak level of knowledge about DNR among the general public. Females, divorced, and those who had a post-graduate level of education were more likely to be knowledgeable of DNR compared to others (p < 0.05). Around one-quarter of the study participants showed agreement with DNR. More than half of them (59.5%) believe that physicians should be involved in DNR decision making. Conclusions: Saudi Arabia’s general community has limited knowledge of DNR. It is recommended that healthcare professionals increase patients’ and caregivers’ understanding of this concept. This will improve the planning and the provision of end-of-life care. Full article

To evaluate how the COVID-19 pandemic impacted the quality of end-of-life care for patients with advanced cancer, we compared a random sample of 250 inpatient deaths from 1 April 2019, to 31 July 2019, with 250 consecutive inpatient deaths from 1 April 2020, to 31 July 2020, at a comprehensive cancer center. Sociodemographic and clinical characteristics, the timing of palliative care referral, timing of do-not-resuscitate (DNR) orders, location of death, and pre-admission out-of-hospital DNR documentation were included. During the COVID-19 pandemic, DNR orders occurred earlier (2.9 vs. 1.7 days before death, p = 0.028), and palliative care referrals also occurred earlier (3.5 vs. 2.5 days before death, p = 0.041). During the pandemic, 36% of inpatient deaths occurred in the Intensive Care Unit (ICU) and 36% in the Palliative Care Unit, compared to 48 and 29%, respectively, before the pandemic (p = 0.001). Earlier DNR orders, earlier palliative care referrals, and fewer ICU deaths suggest an improvement in the quality of end-of-life care in response to the COVID-19 pandemic. These encouraging findings may have future implications for maintaining quality end-of-life care post-pandemic. Full article

The aim of the current study is to evaluate the different degrees of hospice care in improving patients’ autonomy in decision-making and reducing aggressiveness of cancer care in terminal-stage cancer patients, especially in reducing polypharmacy and excessive life-sustaining treatments. This was a retrospective cross-sectional study conducted in a single medical center in Taiwan. Patients with advanced cancer who died in 2010–2019 were included and classified into three subgroups: hospice ward admission, hospice shared care, and no hospice care involvement. In total, 8719 patients were enrolled, and 2097 (24.05%) admitted to hospice ward; 2107 (24.17%) received hospice shared care, and 4515 (51.78%) had no hospice care. Those admitted to hospice ward had significantly higher rates of having completed do-not-resuscitate order (100%, p < 0.001) and signed the do-not-resuscitate order by themselves (48.83%, p < 0.001), and they had lower aggressiveness of cancer care (2.2, p < 0.001) within the 28 days before death. Hospice ward admission, hospice shared care, and age > 79 years were negatively associated with aggressiveness of cancer care. In conclusion, our study showed that patients with end-of-life hospice care related to higher patient autonomy in decision-making and less excessively aggressive cancer care; the influence of care was more overt in patients approaching death. Further clinical efforts should be made to clarify the patient and the families’ satisfaction and perceptions of quality after hospice care involvement. Full article

Background: Intensive care medical technology increases the survival rate of critically ill patients. However, life-sustaining treatments also increase the probability of non-beneficial medical treatments given to patients at the end of life. Objective: This study aimed to analyse whether patients with a do-not-resuscitate (DNR) order were more likely to be subject to the withholding of cardiac resuscitation and withdrawal of life-sustaining treatment in the ICU. Methods: This retrospective study collected data regarding the demographics, illness conditions, and life-sustaining treatments of ICU patients who were last admitted to the ICU between 1 January 2016 and 31 December 2017, as determined by the hospital’s electronic medical dataset. Results: We identified and collected data on 386 patients over the two years; 319 (82.6%) signed a DNR before the end. The study found that DNR patients were less likely to receive cardiac resuscitation before death than non-DNR patients. The cardiac resuscitation treatments included chest compressions, electric shock, and cardiotonic drug injections (p < 0.001). However, the life-sustaining treatments were withdrawn for only a few patients before death. The study highlights that an early-documented DNR order is essential. However, it needs to be considered that promoting discussions of time-limited trials might be the solution to helping ICU terminal patients withdraw from non-beneficial life-sustaining treatments. Full article

Background: To analyze the long-term outcomes for advanced cancer patients admitted to an intermediate care unit (ImCU), an analysis of a do not resuscitate orders (DNR) subgroup was made. Methods: A retrospective observational study was conducted from 2006 to January 2019 in a single academic medical center of cancer patients with stage IV disease who suffered acute severe complications. The Simplified Acute Physiology Score 3 (SAPS 3) was used as a prognostic and severity score. In-hospital mortality, 30-day mortality and survival after hospital discharge were calculated. Results: Two hundred and forty patients with stage IV cancer who attended at an ImCU were included. In total, 47.5% of the cohort had DNR orders. The two most frequent reasons for admission were sepsis (32.1%) and acute respiratory failure (excluding sepsis) (38.7%). Mortality in the ImCU was 10.8%. The mean predicted in-hospital mortality according to SAPS 3 was 51.9%. The observed in-hospital mortality was 37.5% (standard mortality ratio of 0.72). Patients discharged from hospital had a median survival of 81 (30.75–391.25) days (patients with DNR orders 46 days (19.5–92.25), patients without DNR orders 162 days (39.5–632)). The observed mortality was higher in patients with DNR orders: 52.6% vs. 23.8%, p 0 < 0.001. By multivariate logistic regression, a worse ECOG performance status (3–4 vs. 0–2), a higher SAPS 3 Score and DNR orders were associated with a higher in-hospital mortality. By multivariate analysis, non-invasive mechanical ventilation, higher bilirubin levels and DNR orders were significantly associated with 30-day mortality. Conclusion: For patients with advanced cancer disease, even those with DNR orders, who suffer from acute complications or require continuous monitoring, an ImCU-centered multidisciplinary management shows encouraging results in terms of observed-to-expected mortality ratios. Full article

(1) Background: It has been hypothesized that a discrepancy exists in the understanding of a do-not-resuscitate (DNR) order among physicians. We hypothesized that a DNR order signed in the emergency department (ED) could influence the patients’ prognosis after intensive care unit (ICU) admission. (2) Methods: We included patients older than 17 years, who visited the emergency department for non-traumatic disease, who had respiratory failure, required ventilator support, and were admitted to the ICU between January 2010 and December 2016. The associations between DNR and mortality, hospital length of stay (LOS), and medical fees were analyzed. Prolonged hospital LOS was defined as hospital stay ≥75th percentile (≥26 days for the study). Patients were classified as those who did and did not sign a DNR order. A 1:4 propensity score matching was conducted for demographics, comorbidities, and etiology. (3) Results: The study enrolled a total of 1510 patients who signed a DNR and 6040 patients who did not sign a DNR. The 30-day mortality rates were 47.4% and 28.0% among patients who did and did not sign a DNR, respectively. A DNR order was associated with mortality after adjusting for confounding factors (hazard ratio, 1.9; confidence interval, 1.70–2.03). It was also a risk factor for prolonged hospital LOS in survivors (odds ratio, 1.2; confidence interval, 1.02–1.44). Survivors who signed a DNR order were charged higher medical fees than those who did not sign a DNR (217,159 vs. 245,795 New Taiwan Dollars, p < 0.001). (4) Conclusions: Signing a DNR order in the ED increased the ICU mortality rate among patients who had respiratory failure and needed ventilator support. It increased the risk of prolonged hospital LOS among survivors. Finally, signing a DNR order was associated with high medical fees among survivors. Full article

Background: 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. Objective: 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. Method: 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. Results: 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. Conclusions: 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. Full article

Background: There are limited data regarding the outcome of in-hospital cardiopulmonary resuscitation (CPR) in COVID-19 patients. In this study, we compared the outcomes of in-hospital cardiac arrests (IHCA) before and at the peak of the COVID-19 pandemic at Montefiore Medical Center in the Bronx, New York, United States. We also identified the most common comorbidities associated with poor outcomes in our community. Methods: This was a multi-site, single-center, retrospective, observational study. Inclusion criteria for COVID patients were all confirmed positive cases who had in-hospital cardiac arrest (IHCA) between 1 March 2020 and 30 June 2020. The non-COVID cohort included all cardiac arrest cases who had IHCA in 2019. We excluded all out-of-hospital cardiac arrest (OHCA). We compared actual survival to that predicted by the GO-FAR score, a validated prediction model for determining survival following IHCA. Results: There were 334 cases in 2019 compared to 450 cases during the specified period in 2020. Patients who initially survived cardiac arrest but then had their code statuses changed to do not resuscitate (DNR) were excluded. Groups were similar in terms of sex distribution, and both had an average age of about 66 years. Seventy percent of COVID patients were of Black or Hispanic ethnicity. A shockable rhythm was present in 7% of COVID patients and 17% of non-COVID patients (p < 0.05). COVID patients had higher BMI (30.7 vs. 28.4, p < 0.05), higher prevalence of diabetes mellitus (58% vs. 38%, p < 0.05), and lower incidence of coronary artery disease (22% vs. 35%, p < 0.05). Both groups had almost similar predicted average survival rates based on the GO-FAR score, but only 1.5% of COVID patients survived to discharge compared to 7% of non-COVID patients (p < 0.05). Conclusion: The rate of survival to hospital discharge in COVID-19 patients who suffer IHCA is worse than in non-COVID patients, and lower than that predicted by the GO-FAR score. This finding may help inform our patient population about risk factors associated with high mortality in COVID-19 infection, as well as educate hospitalized patients and healthcare proxies in the setting of code status designation. Full article

In the strictest sense, do-not-resuscitate (DNR) status means that cardiopulmonary resuscitation should not be performed after death has occurred; all other medical interventions in line with a patient’s goals of care should be implemented. The use of transthoracic echocardiography (TTE) in patients with DNR status is unknown. Therefore, we aim to evaluate the utilization of TTE among patients with DNR status using this retrospective data analysis. A total of 16,546 patient admissions were included in the final study. A total of 4370 (26.4%) of the patients had a TTE during hospitalization; among full code patients, 3976 (25.7%) underwent TTE, whereas TTEs were performed in 394 (37.4%) of DNR patients. On univariate logistic regression analysis, full code status had OR (95% confidence interval, CI) 0.57 (0.51–0.66), p < 0.01 compared with DNR status for the performance of inpatient TTE. In the final multivariate model adjusted for age, sex, race, and clinical comorbidities, the full code patients had OR (95% CI) 0.91 (0.79–1.05), p = 0.22 compared with DNR patients for the performance of inpatient TTE. DNR status is not associated with a decrease in inpatient transthoracic echocardiography performance. Full article

Cancer patients and their family caregivers experience various losses when patients become terminally ill, yet little is known about the grief experienced by patients and caregivers and factors that influence grief as patients approach death. Additionally, few, if any, studies have explored associations between advance care planning (ACP) and grief resolution among cancer patients and caregivers. To fill this knowledge gap, the current study examined changes in grief over time in patients and their family caregivers and whether changes in patient grief are associated with changes in caregiver grief. We also sought to determine how grief changed following the completion of advance directives. The sample included advanced cancer patients and caregivers (n = 98 dyads) from Coping with Cancer III, a federally funded, multi-site prospective longitudinal study of end-stage cancer care. Participants were interviewed at baseline and at follow-up roughly 2 months later. Results suggest synchrony, whereby changes in patient grief were associated with changes in caregiver grief. We also found that patients who completed a living will (LW) experienced increases in grief, while caregivers of patients who completed a do-not-resuscitate (DNR) order experienced reductions in grief, suggesting that ACP may prompt “grief work” in patients while promoting grief resolution in caregivers. Full article