title: Trends of Do-Not-Resuscitate Orders, Hospice Care Utilization, and Late Referral to Hospice Care among Cancer Decedents in a Tertiary Hospital in Taiwan between 2008 and 2014: A Hospital-Based Observational Study.
abstract: Out of respect for terminal patients' dignity and to decrease end-of-life suffering, patients in Taiwan can choose to sign do-not-resuscitate (DNR) orders and use hospice care when they are in a terminal condition.
  
  
  
  To explore the trends and characteristics of hospice care utilization and DNR status among terminal cancer patients. Design and Setting/Subjects: A secondary data analysis was conducted to examine the rate of DNR orders, hospice care utilization, the survival time after DNR order, the duration of survival (DOS) after hospice care enrollment, and the rate of late referral to hospice care among patients who died from malignant cancers in a tertiary hospital in Taiwan between 2008 and 2014.
  
  
  
  Of the 7857 patients, 7392 (94.1%) had signed a DNR order and 3965 (50.5%) had received hospice care. The rates of DNR orders and hospice care utilization were significantly different across sexes, cancer types, and admission departments (p < 0.001). From 2008 through 2014, the overall hospice utilization rate grew from 39.9% to 57.9% (p < 0.001), with increasing trends among most departments. The survival time after DNR order significantly increased (p < 0.001), and the DOS showed no significant trend (p = 0.404) but late referral rate increased from 29.4% to 35.7% (p = 0.005).
  
  
  
  The hospice care utilization among terminal cancer patients increased in most specialty departments from 2008 through 2014. The DOS did not increase, but the rate of late referrals increased. Further research should be conducted to investigate the factors behind late referrals and non-growing DOS.
authors.affiliation: 1 Baihe Veterans Home, Tainan City, Taiwan .|2 Department of Family Medicine, Taipei Veterans General Hospital , Taipei City, Taiwan .
authors.forename: Tzu-Chien
authors.initials: TC
authors.lastname: Shih
authors.affiliation: 2 Department of Family Medicine, Taipei Veterans General Hospital , Taipei City, Taiwan .|3 School of Medicine, National Yang-Ming University , Taipei City, Taiwan .
authors.forename: Hsiao-Ting
authors.initials: HT
authors.lastname: Chang
authors.affiliation: 2 Department of Family Medicine, Taipei Veterans General Hospital , Taipei City, Taiwan .|3 School of Medicine, National Yang-Ming University , Taipei City, Taiwan .|4 Institute of Public Health, National Yang-Ming University , Taipei City, Taiwan .
authors.forename: Ming-Hwai
authors.initials: MH
authors.lastname: Lin
authors.affiliation: 5 Department of Radiology, Taipei Veterans General Hospital , Taipei City, Taiwan .|6 Institute of Clinical Medicine, National Yang-Ming University , Taipei City, Taiwan .
authors.forename: Chun-Ku
authors.initials: CK
authors.lastname: Chen
authors.affiliation: 2 Department of Family Medicine, Taipei Veterans General Hospital , Taipei City, Taiwan .|3 School of Medicine, National Yang-Ming University , Taipei City, Taiwan .|7 Institute of Hospital and Health Care Administration, National Yang-Ming University , Taipei City, Taiwan .
authors.forename: Tzeng-Ji
authors.initials: TJ
authors.lastname: Chen
authors.affiliation: 2 Department of Family Medicine, Taipei Veterans General Hospital , Taipei City, Taiwan .|3 School of Medicine, National Yang-Ming University , Taipei City, Taiwan .
authors.forename: Shinn-Jang
authors.initials: SJ
authors.lastname: Hwang
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005544:Forecasting; D017051:Hospice Care / Q000706:statistics & numerical data* / Q000639:trends*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000451:nursing*; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D016414:Resuscitation Orders; D013624:Taiwan; D062606:Tertiary Care Centers / Q000706:statistics & numerical data*
keywords: do not resuscitate; hospice care utilization; late referral; terminal cancer patients