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Patient comforting a loved-one.

Do not resuscitate: the benefits of an early decision

1 October 2013
Providing information about do-not-resuscitate instructions to terminally ill patients leads to fewer of them dying in a hospital environment, a University of Sydney study has found.

"Research consistently shows people prefer to die outside of hospital," said Louise Sharpe, Professor of Clinical Psychology, at the University and lead author of the study recently published in the Journal of Clinical Oncology. "Dying in a non-hospital environment also means savings for our health care system."

"This is the first study to show that providing incurable cancer patients with detailed information about signing do-not-resuscitate (DNR) orders leads to fewer patients ending their life in a hospital."

The high profile death of terminally ill Sydney woman Aina Ranke last week highlighted a case of someone wishing to control their death. Many people may not choose to completely control their deaths, as Ranke did, but increasing numbers do not want to be revived if they go into cardiopulmonary arrest, a common cause of death for cancer patients.

"Terminally ill patients require resuscitation in the event of cardiopulmonary arrest, unless they have a DNR order," said Professor Sharpe.

Up to 67 percent of patients with terminal cancer who were admitted without a DNR order were administered cardiopulmonary rehabilitation (CPR), with less than five percent surviving the admission.

"Research shows that terminally ill patients who receive mechanical ventilation are less likely to survive the admission," said Professor Sharpe.

Late DNR orders often result in increased hospital costs and patients receiving inappropriate life-sustaining treatments.

While it is recommended doctors raise the issue with patients early there is no national policy or standardised information on DNRs. In practice there are wide variations in how early a patient is told about the orders. Few patients in the study had already discussed it with their doctor.

"Our study showed that actively informing patients about their DNR options led to earlier DNR orders being made compared to a control group who were not offered that information."

120 Sydney patients with incurable cancer and a prognosis of three to 12 months took part in the study. The intervention regarding DNRs was a discussion with a psychologist and an information pamphlet. Nineteen percent of the intervention group died in hospital compared with 50 percent of the control group.

"Importantly, those who were invited to think about the circumstances and given information were not made more anxious or depressed by the intervention. This is consistent with the literature showing that discussion of end-of-life topics is not harmful to patients," said Professor Sharpe.

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