title: "Allow Natural Death" versus "Do Not Resuscitate": What Do Patients with Advanced Cancer Choose?
abstract: BACKGROUND
  Many patients with advanced cancer at our hospital request full resuscitative efforts at the end of life. We assessed the knowledge and attitudes of these patients towards end-of-life (EOL) care, and their preferences about "Do Not Resuscitate" (DNR), "Allow Natural Death" (AND), and "full code" orders.
  
  
  METHODS
  The first 100 consenting adult patients with advanced cancer were surveyed regarding their diagnosis, prognosis, and attitudes about critical care and resuscitation. They were then presented with hypothetical scenarios in which a decision on their code status had to be made if they had one year, six months, or one month left to live. Half were given a choice between being "full code" and "DNR," and half could choose between "full code" and "AND."
  
  
  RESULTS
  All 93 of the participants who completed the survey were considered by their attending physician to have a terminal illness, but only 42% of these interviewees believed they were terminally ill. In addition, only 25% of participants thought that their primary oncologist knew their EOL wishes. Participants were equally likely to choose either of the "no code" options in all hypothetical scenarios (p>0.54), regardless of age, sex, race, type of cancer, education, or income level. A similar proportion of patients who had a living will chose "AND" and "DNR" orders instead of "full code" in all the scenarios (47%-74% and 63%-71%). In contrast, among patients who did not have a living will, 52% chose "DNR," while 19% opted for "AND."
  
  
  CONCLUSIONS
  We hypothesized that "AND" orders may be more acceptable to patients with advanced cancer, but there was no statistically significant difference in acceptability between "AND" and "DNR" orders.
authors.affiliation: 1 Medical Oncology Service, National Cancer Institute , Bethesda, Maryland.
authors.forename: Miloš D
authors.initials: MD
authors.lastname: Miljković
authors.forename: Dennis
authors.initials: D
authors.lastname: Emuron
authors.forename: Lori
authors.initials: L
authors.lastname: Rhodes
authors.forename: Joseph
authors.initials: J
authors.lastname: Abraham
authors.forename: Kenneth
authors.initials: K
authors.lastname: Miller
mesh_terms: D000328:Adult; D016223:Advance Directives / Q000523:psychology* / Q000706:statistics & numerical data; D000368:Aged; D000369:Aged, 80 and over; D001293:Attitude to Death; D002755:Choice Behavior; D003142:Communication; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000523:psychology* / Q000628:therapy; D057240:Patient Preference / Q000523:psychology / Q000706:statistics & numerical data; D016414:Resuscitation Orders / Q000523:psychology*; D013727:Terminal Care / Q000523:psychology* / Q000592:standards / Q000706:statistics & numerical data; D019452:Terminally Ill / Q000523:psychology* / Q000706:statistics & numerical data
references.citation: J Palliat Med. 2010 May;13(5):513-7
references.pmid: 20192843
references.citation: Arch Intern Med. 1994 Apr 25;154(8):909-13
references.pmid: 8154954
references.citation: Hastings Cent Rep. 2004 May-Jun;34(3):49
references.pmid: 15281726
references.citation: J Palliat Med. 2011 Nov;14(11):1231-5
references.pmid: 21877925
references.citation: Crit Care Med. 2013 Jul;41(7):1686-91
references.pmid: 23660727
references.citation: Am J Hosp Palliat Care. 2013 Jun;30(4):363-9
references.pmid: 22777405
references.citation: J Healthc Qual. 2008 Sep-Oct;30(5):55-63
references.pmid: 18831477
references.citation: J Clin Oncol. 2013 Jan 20;31(3):380-6
references.pmid: 23233708
references.citation: J Palliat Med. 2013 Jun;16(6):623-31
references.pmid: 23725233
references.citation: Cancer Nurs. 2009 Jul-Aug;32(4):335-41
references.pmid: 19444078
references.citation: Am J Hosp Palliat Care. 2011 Dec;28(8):543-9
references.pmid: 21454317
references.citation: J Palliat Med. 2000 Spring;3(1):27-35
references.pmid: 15859719
references.citation: J Med Ethics. 2008 Jan;34(1):2-6
references.pmid: 18156510