title: Do-not-resuscitate consent signed by patients indicates a more favorable quality of end-of-life care for patients with advanced cancer.
abstract: Do-not-resuscitate (DNR) consent is crucial in end-of-life (EOL) care for patients with advanced cancer. However, DNR consents signed by patients (DNR-P) and surrogates (DNR-S) reflect differently on patient autonomy and awareness.
  
  
  
  This retrospective study enrolled advanced cancer patients treated at National Taiwan University Hospital, Hsin-Chu Branch between 2012 and 2014. Patients who signed DNR consent at other hospitals were excluded; the remaining patients were subsequently classified into DNR-S and DNR-P groups.
  
  
  
  We enrolled 1495 patients. The most prevalent primary cancers were hepato-biliary-pancreatic (26.9 %), lung (16.3 %), and colorectal (14.0 %) cancers. We classified 965 (64.5 %) and 530 (35.5 %) patients into the DNR-S and DNR-P groups, respectively. Significant differences were observed between both groups regarding gender (p = 0.002), age (p < 0.001), and the Eastern Cooperative Oncology Group performance (p < 0.001) and educational (p < 0.001) status levels. The median survival times after DNR consent signature were 5.0 days (95 % confidence interval [CI] 4.4-5.6 days) and 14.0 days (95 % CI 12.1-15.9 days) in the DNR-S and DNR-P groups, respectively (p < 0.001). The median good death evaluation (GDE) scores were 5.4 (95 % CI 4.9-6.0) and 13.7 (95 % CI 12.7-14.6) in the DNR-S and DNR-P groups, respectively (p < 0.001). Univariate and multivariate analyses revealed that DNR-S was an independent factor for significantly low GDE scores (i.e., poor EOL care quality).
  
  
  
  The DNR concept is emerging; however, the DNR-P percentage remains low (35.6 %) in patients with advanced cancer. DNR-P significantly improves the EOL care quality.
authors.affiliation: Department of Oncology, National Taiwan University Hospital, No. 7, Chung-Shan South Rd, Taipei, 10002, Taiwan.|Department of Oncology, National Center of Excellence for Clinical Trial and Research, National Taiwan University Hospital, Taipei City, Taiwan.|Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taipei City, Taiwan.
authors.forename: Yi-Hsin
authors.initials: YH
authors.lastname: Liang
authors.affiliation: Department of Oncology, National Taiwan University Hospital, No. 7, Chung-Shan South Rd, Taipei, 10002, Taiwan.
authors.forename: Chih-Hsin
authors.initials: CH
authors.lastname: Wei
authors.affiliation: Department of Nursing, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu City, Taiwan.
authors.forename: Wen-Hui
authors.initials: WH
authors.lastname: Hsu
authors.affiliation: Department of Oncology, National Center of Excellence for Clinical Trial and Research, National Taiwan University Hospital, Taipei City, Taiwan.|Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taipei City, Taiwan.
authors.forename: Yu-Yun
authors.initials: YY
authors.lastname: Shao
authors.affiliation: Department of Nursing, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu City, Taiwan.
authors.forename: Ya-Chin
authors.initials: YC
authors.lastname: Lin
authors.affiliation: Department of Nursing, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu City, Taiwan.
authors.forename: Pei-Chun
authors.initials: PC
authors.lastname: Chou
authors.affiliation: Department of Oncology, National Center of Excellence for Clinical Trial and Research, National Taiwan University Hospital, Taipei City, Taiwan.|Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taipei City, Taiwan.|Department of Internal Medicine, National Center of Excellence for Clinical Trial and Research, National Taiwan University Hospital, Taipei City, Taiwan.|Center for Comparative Effectiveness Research, National Center of Excellence for Clinical Trial and Research, National Taiwan University Hospital, Taipei City, Taiwan.
authors.forename: Ann-Lii
authors.initials: AL
authors.lastname: Cheng
authors.affiliation: Department of Oncology, National Taiwan University Hospital, No. 7, Chung-Shan South Rd, Taipei, 10002, Taiwan. khyeh@ntu.edu.tw.|Department of Oncology, National Center of Excellence for Clinical Trial and Research, National Taiwan University Hospital, Taipei City, Taiwan. khyeh@ntu.edu.tw.|Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taipei City, Taiwan. khyeh@ntu.edu.tw.|Center for Comparative Effectiveness Research, National Center of Excellence for Clinical Trial and Research, National Taiwan University Hospital, Taipei City, Taiwan. khyeh@ntu.edu.tw.|Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei City, Taiwan. khyeh@ntu.edu.tw.
authors.forename: Kun-Huei
authors.initials: KH
authors.lastname: Yeh
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D005260:Female; D017051:Hospice Care / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000628:therapy*; D016414:Resuscitation Orders / Q000941:ethics*; D012189:Retrospective Studies; D013727:Terminal Care / Q000379:methods*; D055815:Young Adult
keywords: Advanced cancer; Do-not-resuscitate; End-of-life care; Terminal