title: Characteristics of patients who refuse do-not-resuscitate orders upon admission to an acute palliative care unit in a comprehensive cancer center.
abstract: BACKGROUND
  Refusal of appropriately indicated do-not-resuscitate (DNR) orders may cause harm and distress for patients, families, and the medical team. We conducted a retrospective study to determine the frequency and predictors of refusals of DNR in advanced cancer patients admitted to an acute palliative care unit.
  
  
  METHODS
  A total of 2538 consecutive admissions were reviewed. Demographic and clinical characteristics from 200 consecutive patients with DNR orders and 100 consecutive patients who refused DNR were collected, and differences between the groups were determined by multivariate regression and recursive partitioning analysis.
  
  
  RESULTS
  Of 2538 admissions, 2530 (99%) were appropriate for DNR discussion. Of the 2530 admissions, 2374 were unique patients, and 100 (4%) of 2374 refused DNR. Refusers had median (interquartile range, IQR) pain of 7 (4-9) versus 5 (3-8, P = .0005), nausea of 2 (0-7) versus 1 (0-4, P = .05), and dyspnea of 1 (0-5) versus 4 (0-7, P = .002) as compared with DNR nonrefusers, respectively. Patients with hematological malignancies and advance directives had a lower DNR refusal risk (odds ratio [OR], 0.38; P = .02, and OR, 0.36; P < .0001, respectively). Multivariate regression analysis revealed that patients with moderate-severe pain (OR, 3.19; P = .002) and with no advance directives (OR, 2.94; P < or = .001) had higher DNR refusal risk. There were more inpatient deaths among DNR nonrefusers (87 of 200 vs 1 of 100, P < .0001). Median (IQR) time from discharge to death was 18 (8-35) days for those with DNR orders and 85 (25-206) days for DNR refusers (P < or = .0001).
  
  
  CONCLUSIONS
  DNR refusal in patients admitted to the acute palliative care unit is low, more frequent in patients with more pain and nausea and no advance directives, and associated with longer survival. This study demonstrates possible predictors of complicated DNR discussions.
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA.
authors.forename: Henrique A
authors.initials: HA
authors.lastname: Parsons
authors.forename: Maxine J
authors.initials: MJ
authors.lastname: de la Cruz
authors.forename: Donna S
authors.initials: DS
authors.lastname: Zhukovsky
authors.forename: David
authors.initials: D
authors.lastname: Hui
authors.forename: Marvin O
authors.initials: MO
authors.lastname: Delgado-Guay
authors.forename: Adenike E
authors.initials: AE
authors.lastname: Akitoye
authors.forename: Badi
authors.initials: B
authors.lastname: El Osta
authors.forename: Lynn
authors.initials: L
authors.lastname: Palmer
authors.forename: Shana L
authors.initials: SL
authors.lastname: Palla
authors.forename: Eduardo
authors.initials: E
authors.lastname: Bruera
mesh_terms: D000328:Adult; D001741:Black or African American; D002173:Cancer Care Facilities; D016022:Case-Control Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009325:Nausea / Q000150:complications; D009369:Neoplasms / Q000175:diagnosis* / Q000401:mortality*; D010146:Pain / Q000150:complications; D010166:Palliative Care; D010342:Patient Acceptance of Health Care; D016414:Resuscitation Orders; D012189:Retrospective Studies; D016019:Survival Analysis