Boston, MA—New research provides hard data demonstrating that having an advance directive with a do not resuscitate (DNR) order leads to a significant cost reduction in the critical care of patients with advanced cancer. The study, reported at the 2014 Palliative Care in Oncology Symposium, is one of the first to quantify the cost-savings that can result when critical care patients with advanced cancer have a DNR. Diane G. Portman, MD, Chair of the Department of Supportive Care Medicine at Moffitt Cancer Center, Tampa, FL, presented the results.
Dr Portman and colleagues examined the cost of care and the length of stay of patients who died in the intensive care unit (ICU) at Moffitt Cancer Center during 2013, based on whether they had an advance directive without a DNR, an advance directive with a DNR, or no advance directive. The cost of care for a regular hospital bed was compared with a stay in the ICU to determine the potential cost-savings of avoiding the ICU.
Moffitt’s Blood and Marrow Transplant (BMT) program has implemented a protocol to obtain a more detailed advance directive before bone marrow transplant because of the high risk of the procedure.
“Studies from other cancer centers have shown that even if critical cancer patients had advance directives, you got little action from them, and the care kind of rolled along on automatic pilot, was very aggressive and often futile,” said Dr Portman.
“Previous studies have shown that we need much tighter discussions about goals and level of care in the ICU cancer population, and that concrete language is needed in the form of a DNR, rather than a traditional advance directive,”she said.
Of the 103 patients with advanced cancer who died in the ICU at the Moffitt Center, when a patient had an advance directive but no DNR, no real impact was seen on costs. “What was very meaningful was having a living will, which usually then also translated into a DNR. It was less likely to have a living will and not have a DNR,” noted Dr Portman.
Despite longer lengths of stay, indicating that DNRs were obtained late in their course, patients who had a DNR still had significantly lower costs of care. The average savings for having a living will and a DNR compared with no advance directive or an advance directive with no living will was roughly $300 per day in the ICU.
The savings, said Dr Portman, was realized through reduced spending on testing, supplies, and pharmaceuticals. The cost of care for patients who did not go to the ICU but stayed in a regular hospital bed was reduced by $2000 daily.
“Once you had the living will, you knew what that patient wanted and you could turn to the patient’s family and say, ‘This is what the patient would have wanted. We are now engaging in futile care,’” said Dr Portman. “We curtailed undesired or futile care more rapidly.”
The researchers also found that the BMT program’s advance directive initiative increased the number of patients with an advance directive on their chart from 41% to 83% in 7 months. Among the 38 patients who had a bone marrow transplant and had died, this resulted in a significant reduction in their length of stay in the ICU by aligning their care with their stated goals. “We need to generalize this initiative more broadly to other patients,” said Dr Portman.