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Do-not-resuscitate order increases likelihood of dying in preferred location

Patients had a significantly greater chance of achieving their preferred place of death with advance care planning that included a documented do-not-resuscitate status, according to findings published in Annals of Internal Medicine.

“Enabling persons to die where they choose is considered a key indicator of quality in end-of-life care,” Thomas Callender, MBChB, from the Royal Marsden NHS Foundation Trust and Imperial College of London in England, and colleagues wrote. “Most persons state that they would prefer to die at home or in a hospice, but more persons in England die in a hospital than in these settings (48% vs. 29%) ... The Coordinate My Care service (CMC) enables persons to create a digital urgent care plan with their clinicians. It is accessible to all health and social care professionals involved in a patient’s care. Coordinate My Care is a unique data set that enables analysis of how prospective patient wishes and documented advance care plans influence end-of-life care.”

To determine the contributing factors for achieving preferred places of death to inform clinically relevant approaches aimed at increasing the number of people fulfilling their wishes, Callender and colleagues analyzed 9,027 adult patients with a CMC plan who had a documented place of death and died between March 1, 2011, and Sept. 31, 2016. They created a multivariable logistic regression model to identify the mutually adjusted factors linked to achievement of preferred place of death. The model included age, sex, diagnosis, WHO performance score, resuscitation status, first choice of place of death and preferred place of care. Patients without a valid order to do-not-resuscitate were categorized as “for resuscitation.”

Approximately 78% of participants died in their preferred location. Nonacute sectors, such as at home, a care home or a hospice, were the preferred place to die for most participants (97.8%).

Death in their preferred place was achieved by 73.8% of participants whose first choice was their home, in 89.7% whose first choice was a care home and in 67.6% whose first choice was a hospice. Choosing to die in a hospital was indicated by more patients with cancer than those with other diagnoses (16.6% vs. 2.8%). About 55% of participants who did not die in their first choice died in a hospital. Women, those with poor performance status and those with a cancer diagnosis were more likely to die in their preferred place. In addition, participants were 76% more likely to die in their choice of location if they had a do-not-resuscitate order (OR = 1.76; 95% CI, 1.56 to 2)

“Given the evidence of poor prognosis after resuscitation in those with advanced incurable disease, our results suggest that these conversations can be considered a positive gateway to achieving a patient’s wishes for their future care,” Callender and colleagues concluded.

“Further research is needed to explore how best to improve the proportion of persons who discuss advance care planning with their clinicians and to overcome perceived barriers to these conversations,” they added. – by Alaina Tedesco

Disclosures: Callender reports no relevant financial disclosures. Please see full study for complete list of all other authors’ relevant financial disclosures.