A retrospective cohort study by Taiwan researchers, published in International Journal of Chronic Obstructive Pulmonary Disease on August 14, shows that 86.3 percent of terminal COPD patients died with a DNR directive, however 70 percent of them made DNR decisions during the last admission and the time period from a DNR directive to death was only 5 days. This research was conducted by PhD candidate Dr. Pin-Kuei Fu, and his advisor, Dr. Duan-Rung Chen, professor at the Institute of Health Behaviors and Community Sciences, and Dr. Yu-Chi Tung, associate professor at the Institute of Health Policy and Management, National Taiwan University College of Public Health. Dr. Pin-Kuei Fu is the director of Respiratory Intensive Care Unit at Taichung Veterans General Hospital, Taichung, Taiwan. His primary research interests are care continuity and palliative care for chronic obstructive pulmonary disease (COPD).
COPD was the 7th leading cause of death in Taiwan in 2015 and was the 3rd leading cause of death worldwide in 2016. The prognosis of advanced COPD was the same as lung cancer, however, advanced COPD patients receive more intensive care and less palliative care then terminal lung cancer patients. In 2000, the Hospice Palliative Care Act (HPCA) became a law in Taiwan. The health care system will pay for palliative care for cancer or non-cancer terminal ill. The aim or this study is to investigate factors associated with an early DNR decision (prior to last hospital admission) and differences in care patterns between patients who made DNR directives early vs late. Dr. Chen’s team has addressed the issue of palliative care in ICU. She helped Dr. Fu to conduct this retrospective cohort study by using electronic health records (EHR) in a medical center in central Taiwan address on this issue.
The current study shows a total of 234 (86.3 percent) patients died with a DNR directive, however only 30 percent were “Early DNR” (EDNR). EDNR was associated with increased age (OR=1.07; 95 percent CI: 1.02–1.12), increased ER visits (OR=1.22; 95 percent CI: 1.10–1.37), rapid decline in lung function (OR=3.42; 95 percent CI: 1.12–10.48), resting heart rate ≥100 (OR=3.02; 95 percent CI: 1.07–8.51), and right-sided heart failure (OR=2.38; 95 percent CI: 1.10–5.19).
The present study confirms that EDNR patients experienced a good death in the last admission because they died less frequently in the ICU (P<0.001), received less frequent mechanical ventilation (MV; P<0.001), had more frequent non-invasive MV (P=0.006), and had a shorter length of hospital stay (P=0.001). These predictive factors may help patients, their surrogates, and primary care physicians to prepare and share decisions about end-of-life issues in advanced COPD.
[Photo: Dr. Duan-Rung Chen. & Dr. Pin-Kuei Fu]