The do-not-resuscitate order: incidence of documentation in the medical records of cancer patients referred for palliative radiotherapy

Patients with symptomatic metastases referred for outpatient palliative radiotherapy for symptom control at the Rapid Response Radiotherapy Program (rrrp) and the Bone Metastases Clinic (bmc) at the Toronto–Sunnybrook Regional Cancer Centre have a limited life expectancy. Relevant medical information is missing from the files of many referred patients when they arrive at the clinics, potentially causing delayed treatment and ambiguity in the best management of their needs in situations of worsening condition. Clear documentation of the do-not-resuscitate (dnr) order is imperative to avoid panic and the taking of unnecessarily aggressive measures in situations in which cardiopulmonary resuscitation (cpr) has no benefit or is not desired. Here, we report the current practices of cpr code status documentation for patients referred to the rrrp and the bmc for out-patient palliative radiotherapy. We reviewed referral notes and accompanying medical records for 209 consecutive patients seen in the rrrp and the bmc during May–August 2004 for documentation of cpr-related advance directives. Patient demographics and cancer history were also recorded. Only 13 (6.2%) of the 209 patients had any documented reference to cpr code status. Of these 13 patients, 8 were dnr-coded, and 5 were full code. As compared with patients having no documented cpr code status, patients with documented status were significantly older (median age: 77 years; p = 0.0347), had poorer performance status (median Karnofsky performance status score: 40; p = 0.0001), and were more likely to be referred hospital inpatients (69%, p = 0.0004). Only a small proportion of symptomatic advanced cancer patients had any documentation of cpr code status upon referral for outpatient palliative radiotherapy. In future, our clinics plan to request information about cpr code status on our referral form.