Characteristics of patients who refuse medically appropriate do not resuscitate orders (DNR) upon admission to a palliative care (PC) unit in a comprehensive cancer center
Bibliographic record
Abstract
9589 Background: Cardiopulmonary resuscitation (CPR) has limited benefit in advanced cancer patients (pts). Refusal of medically appropriate DNR (maDNR) may cause harm and distress for pts, families, and the medical team. We conducted a retrospective study to determine the frequency of refusals of maDNR in a tertiary PC unit in a comprehensive cancer center, and characterize the differences between maDNR acceptors (A) and refusers (R). Methods: We reviewed 2538 consecutive admissions to the PC unit to find refusals of maDNR. Data were collected regarding demographical/clinical factors, 0–10 Edmonton Symptom Assessment System, DNR, CPR, and death for the first 100 R and 200 A pts. Results: DNR was considered medically appropriate for 2530/2538 (99%) admissions. 2374/2530 admissions were of unique pts, and 100/2374 (4%) refused maDNR. 3/3 (100%) R pts who coded underwent CPR versus 0/87 A pts who coded (0%, p<0.0001). 2/3 CPR pts survived code and were discharged but died in less than 10 days. Median age (62), female gender (54%), and religious affiliation were not different between R and A. African-Americans and pts with head and neck malignancies were more frequently R than others (OR=1.99, CI=1.13–3.51, p=0.02 and OR=2.62, CI=1.05–6.56, p=0.04, respectively). A had more hematological malignancies and advance directives (OR=2.66, CI=1.07–6.63, p=0.02, and OR=2.80, CI=1.68–4.66, p<0.0001, respectively). Multivariate regression analysis revealed that pts with hematologic malignancies (OR 2.69, CI=1.05–6.90 p= 0.04) and advance directives (OR 1.46, CI=1.46–4.27, p= 0.001) were associated with A. R pts presented with median (interquartile range, IR) pain of 7(4–9) vs 5(3–8, p=0.0005) nausea of 2(0–7) vs 1(0–4, p=0.05), and dyspnea of 1(0–5) vs 4(0–7, p=0.002). Median (IR) time between PC consult and death and discharge and death were 143 (49–329) days for R vs 25(10–77) for A (p<0.0001) and 85 (25–206) for R and 18 (8–35) for A (p<0.0001). Conclusions: DNR refusal in pts after PC consult is low, more frequent among African Americans, pts with head and neck cancers, pts with more pain or nausea, and is associated with longer survival. This study demonstrates possible predictors of complicated DNR discussions. No significant financial relationships to disclose.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.004 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.001 | 0.000 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".