Journal ofMedical Ethics 1999;25:309-314 J Med Ethics: first published as 10.1136/jme.25.4.309 on 1 August 1999. Downloaded from The status of the do-not-resuscitate order in Chinese clinical trial patients in a cancer centre Jacqueline Ming Liu, Wei Chun Lin, Yuh Min Chen, Hsiao Wei Wu, Nai Shun Yao, Li Tzong Chen and Jacqueline Whang-Peng National Health Research Institutes, Veterans General Hospital, Taipei and National Yang Ming University, Taipei, Taiwan, Republic of China Abstract encing cessation in cardiac function.' Cardiopul- Objective-To report and analyse the pattern of monary resuscitation has since then been auto- end-of-life decision makingfor terminal Chinese matically administered to any individual who has cancer patients. experienced abrupt cessation in cardiac or respira- Design-Retrospective descriptive study. tory function,2 3 unless otherwise prohibited. Setting-A cancer clinical trials unit in a large In the 1980s in the USA, CPR was performed in teaching hospital. about a third of all hospitalised persons before Patients-From April 1992 to August 1997, 177 dying.4 After the first CPR, pulse and blood consecutive deaths of cancer clinical trial patients pressure could be established in 30-40% of were studied. patients,4 although vital signs had to be restored to be 6 10-40% Main measurement-Basic demographic data, within 30 minutes effective,5 copyright. patient status at the time ofsigning a DNR consent, survived 24 hours,5 7 but only 14-17% lived to hos- or at the moment of returning home to die are pital discharge,7 10 and 11% of patients actually documented, and circumstances surrounding these required a second CPR whilst still in hospital.8 For- events evaluated. tunately, of those discharged after a successful Results-DNR orders were written for 64.44% of CPR, more than 90% remained mentally intact.51' patients. Patients in pain (odds ratio 0. 45, 95%CI Analysis has shown that pneumonia, hypoten- 0.22-0.89), especially if requiring opioid analgesia sion, renal failure, cancer, sepsis, and a home- http://jme.bmj.com/ (odds ratio 0.40, 95%CI 0.21-0.77), were factors bound lifestyle predict for CPR failure with associated with a higher probability ofsuch an order. significant in-hospital mortality.5 7 10 12 13 Predic- Thirty-five patients were taken home to die, a more tors of survival after CPR were formulated from likely occurrence if the patient was over 75 years composite evaluation of patient age, diagnoses, (odds ratio 0.12, 95%CI 0.04-0.34), had children mental status, and physical condition, and pa- (odds ratio 0.14, 95%CI 0.02-0.79)_,had Taiwanese tients who were unlikely to benefit from CPR as a first language (odds ratio 6.74, 95%CI counselled against it,' 1'4 guidelines for do-not- on September 25, 2021 by guest. Protected 3.04-14.93), or was unable to intake orally (odds resuscitate orders were thus formulated.3 7 ratio 2.73, 95%CI 1. 26-5.92). CPR was performed The rationale behind a DNR order is threefold: in 30 patients, none survived to discharge. the patient will receive no medical benefit, and at Conclusions-DNR orders are instituted in a large most short-term life prolongation after CPR (a proportion ofdying Chinese cancer patients in a physician-dependent judgment); poor quality of cancer centre, however, the order is seldom signed by life is expected after CPR, and CPR should also be the patient personally. This study also illustrates that deferred if there is poor quality of life before car- as many as 20% ofdying patients are taken home to diopulmonary arrest, the last two dependent on die, in accordance with local custom. 14 (Journal Medical Ethics 1999;25:309-314) patient standards. The DNR order has the of of decreased mechanical ventilation Keywords: DNR: do not resuscitate; AAD: discharge advantage against advice; CPR: cardiopulmonary resuscitation; end- support, decreased traumatic preterminal inter- of-life directives vention for the patient, and in general, decreased economic expenses, but an associated higher Introduction in-hospital mortality, even after stratification for Cardiopulmonary resuscitation (CPR) was first severity of illness.'5 described in 1960; patients were successfully Once a DNR order is in place there follows the revived by external cardiac massage after experi- inevitable generalisation of that management 310 The status of the do-not-resuscitate order in Chinese clinical trial patients in a cancer centre J Med Ethics: first published as 10.1136/jme.25.4.309 on 1 August 1999. Downloaded from principle to other treatments, which means that Table 1 Demographic data of 177 Chinese cancer clinical auxiliary care available to the patient can be highly trial patients variable, since at one extreme it might be seen as necessary to perform all possible treatment up to Parameter but excluding CPR, while at the other extreme Mean age, years (range) 56.5 (19-80) Male:female ratio 113:64 treatment is limited to comfort measures only.'6 Marital status, No (%) Nevertheless, appropriate institution of nutrition Married 154 (87) and hydration should never be overlooked.'7 Single 20 (11) Divorced 3 (2) With DNR orders being written for 9-20% of all Children number, No (%) (single patients inpatients,'3 19-22 68-86% of all dying patients,'6 21 excluded) 3 (0-8) 85-94% of cancer patients,23 it is obvious they 0 7 (4.4) 1 18 (12) have wide ranging ethical, legal and economic >2 132 (75) implications. Educational level, No ('X) In the Chinese culture as observed on Taiwan, it Illiterate 21 (12) Literate 6 (3.4) is preferable that dying people exhale their last Primary school 62 (35) breath at home, signifying a full life, bringing good Secondary school 56 (32) College and beyond 32 (18) fortune to future descendants.24 To fulfil that wish, Language, No (0) the patient is sometimes intubated to maintain an Mandarin 147 (83) airway for manual ventilation, regardless of Taiwanese 30 (17) cardiac status, and only extubated Diagnosis, No (0) at home. This Lung cancer 56 (32) study was designed to report and analyse end-of- Gastrointestinal cancers (hepatoma, gastric, life directives of Chinese cancer patients. colon and pancreaticobiliary cancers) 46 (26) Breast 17 (10) Nasopharyngeal carcinoma 21 (12) Material and methods Metastases of unknown origin 16 (9) Miscellaneous 21 (12) This study is a retrospective, descriptive study. Religion, No (0) Between April 1992, and August 1997, 177 Buddhism/Taoism 91 (51) copyright. consecutive deaths of patients registered on Christianity 21 (12) various clinical trial protocols in our cancer None 65 (36) research centre were studied: all patients had detailed medical records, including a detailed account of circumstances surrounding their de- their circumstance by the family or friends, and in mise. Patient diagnoses included 56 lung cancers, the overwhelming majority of cases, the medical 46 gastrointestinal cancers, 21 nasopharyngeal team was asked to do the same. To our knowledge,http://jme.bmj.com/ cancers, 17 breast cancers, 16 cancers ofunknown none of the patients had made a living will. primary site, and a miscellaneous group of Cardiopulmonary resuscitation is defined as ovarian, cervical cancers, and melanoma. application of external chest compressions and Informed consent for treatment, as approved by rescue breathing.' AAD stands for discharge the Veterans General Hospital, Taipei institutional against advice, but in the context of this review committee, was obtained from all patients manuscript, it implies, without exception, that the prior to registration for their particular clinical patient has to be taken to his/her own home to on September 25, 2021 by guest. Protected trial, and thus all patients had their diagnosis, exhale the last breath, a decision that may be treatment, expected therapeutic efficacy, and pro- patient and/or family directed. DNR means do jected survival formally explained to them in not resuscitate. The DNR consent form, more detail, culminating in them signing an informed correctly, the CPR refusal form, is not considered consent for treatment. a legal document in Taiwan, but signing such a At the point when all active therapy became futile form still implies prohibition of external chest for a particular patient, the family members, but compression, intubation and artificial ventilation. seldom the patient directly, since direct patient In this study, the terms DNR order and the with- communication is not legally required, would be hold CPR order will be used interchangeably. informed of the seriousness of the situation, Statistical analysis to determine variables im- consulted about communication with the patient, portant in a patient signing a refusal for CPR, or and prompted to make future arrangements, a ses- choosing to conform to custom and die at home, sion usually lasting 15 to 20 minutes. It is important or even insisting upon CPR, was performed by to state that in this group of cancer patients, DNR X-square test with odds ratio for analysis of was discussed with the rationale that CPR would be categorical data, and was considered significant if futile as a result of progressive cancer.'4 However, p<0.05. Survival was calculated by the Kaplan- the patients were seldom given a clear account of Meir method with Logrank test. Liu, Lin, Chen, et al 311 J Med Ethics: first published as 10.1136/jme.25.4.309 on 1 August 1999. Downloaded from Table 2 Patient status at the time ofsigning the DNR consent, Table 3 Details relating to the DNR order and eventual cause andlor the time ofchoosing