• Pin-Kuei Fu, Ming-Chin Yang, Chen-Yu Wang, Shin-Pin Lin, Chen-Tsung Kuo, Chiann-Yi Hsu, and Yu-Chi Tung.
• Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan; Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; College of Human Science and Social Innovation, Hungkuang University, Taichung, Taiwan; Science College, Tunghai University, Taichung, Taiwan.
• J Pain Symptom Manage. 2019 Dec 1; 58 (6): 968-976.

ContextNearly 70% of do-not-resuscitate (DNR) directives for chronic obstructive pulmonary disease (COPD) patients are established during their terminal hospitalization. Whether patient use of end-of-life resources differs between early and late establishment of a DNR is unknown.ObjectivesThe objective of this study was to compare end-of-life resource use between patients according to DNR directive status: no DNR, early DNR (EDNR) (established before terminal hospitalization), and late DNR (LDNR) (established during terminal hospitalization).MethodsElectronic health records from all COPD decedents in a teaching hospital in Taiwan were analyzed retrospectively with respect to medical resource use during the last year of life and medical expenditures during the last hospitalization. Multivariate linear regression analysis was used to determine independent predictors of cost.ResultsOf the 361 COPD patients enrolled, 318 (88.1%) died with a DNR directive, 31.4% of which were EDNR. COPD decedents with EDNR were less likely to be admitted to intensive care units (12.0%, 55.5%, and 60.5% for EDNR, LDNR, and no DNR, respectively), had lower total medical expenditures, and were less likely to undergo invasive mechanical ventilator support during their terminal hospitalization. The average total medical cost during the last hospitalization was nearly twofold greater for LDNR than for EDNR decedents. Multivariate linear regression analysis revealed that nearly 60% of medical expenses incurred were significantly attributable to no EDNR, younger age, longer length of hospital stay, and more comorbidities.ConclusionAlthough 88% of COPD decedents died with a DNR directive, 70% of these directives were established late. LDNR results in lower quality of care and greater intensive care resource use in end-of-life COPD patients.Copyright © 2019 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

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