title: Discharge patterns, survival outcomes, and changes in clinical management of hospitalized adult patients with cancer with a do-not-resuscitate order.
abstract: BACKGROUND
  Do-not-resuscitate (DNR) orders prevent medically futile attempts at resuscitation but are not always instituted in hospitalized patients with advanced cancer. One explanation for this underuse is the perception that DNR orders are inevitably associated with withdrawal of all medical interventions and inpatient death.
  
  
  OBJECTIVE
  To audit discharge and survival outcomes and changes in clinical management in hospitalized adult oncology patients with a DNR order, allowing an assessment of whether such orders lead to cessation of acute interventions and high rates of in-hospital death.
  
  
  METHODS
  Retrospective data were collected from 270 oncology inpatients at Austin Health, Melbourne, Australia, between February 1, 2012 and November 30, 2012.
  
  
  RESULTS
  Mean and median time to institution of DNR orders after admission were 2.1 and 1.0 days, respectively (interquartile range, 0-2 days). Medical interventions continued in 80% or more of cases after DNR orders were placed included blood draws, intravenous antimicrobials, imaging, blood products, and radiotherapy. Two-thirds of patients survived hospitalization and were discharged alive. Survival at 30 days and 90 days after DNR orders were implemented was 63% and 33%, respectively. Baseline Charlson Comorbidity Index score of 5 or less and Eastern Cooperative Oncology Group performance status of 2 or less were associated with a higher probability of being discharged alive and longer overall survival.
  
  
  CONCLUSIONS
  Most medical interventions were continued with high frequency in adult oncology inpatients after placement of DNR orders. A majority of patients survived hospitalization and remained alive at 30 days after DNR orders were documented. This study offers some reassurance that DNR orders do not inevitably lead to cessation of appropriate medical treatment.
authors.affiliation: 1 Joint Austin-Ludwig Oncology Unit, Austin Health , Melbourne, Australia .
authors.forename: Arun A
authors.initials: AA
authors.lastname: Azad
authors.forename: Sue-Faye
authors.initials: SF
authors.lastname: Siow
authors.forename: Ali
authors.initials: A
authors.lastname: Tafreshi
authors.forename: Juli
authors.initials: J
authors.lastname: Moran
authors.forename: Michael
authors.initials: M
authors.lastname: Franco
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009369:Neoplasms / Q000401:mortality / Q000628:therapy*; D010351:Patient Discharge / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians'; D016414:Resuscitation Orders; D012189:Retrospective Studies; D016019:Survival Analysis; D014739:Victoria