FACTORS ASSOCIATED WITH ADVANCED CARE DIRECTIVES AND PALLIATIVE CARE

Background: Patients from diverse sociocultural backgrounds and with differing medical conditions may have varying levels of acceptance of advanced care planning which is a process in which patients of any age or health status document future care preferences. It can encompass do-not-resuscitate (DNR) orders, directives to withhold cardiopulmonary resuscitation in the event of cardiac arrest as well as palliative care (PC), focused on improving quality of life by addressing individuals’ physical, psychosocial, and spiritual needs.

Methods: We performed a retrospective analysis of the National Inpatient Sample for patients discharged from January 1, 2016, to December 31, 2019. We only included patients with the following discharge diagnoses: Alzheimer’s disease (ICD10 G30.9, 3G0.1), COPD (J44.9, J44.1), CHF (I50.9, I11.0, I13.0), Senile degeneration of brain (G31.1) lung malignancy (C34.90), Parkinson’s disease (G20), CVA (167.2, 163.9), CVD (I125.10), prostate cancer (C61), colon cancer (C18.9), ESRD (N18.6), pancreatic cancer (C25.9), and sepsis (A41.9). We recorded demographic variables, DNR status, and palliative care status (Pall) and analyzed the associations of the outcomes, mortality, and length of stay (LOS).

Results: There were 23,402,637 a total of patient records included in the study: No DNR/No Pall 92%; DNR and Pall 2%; DNR only 5%; Pall only 1%. From 2016 to 2020, the percentage of patients with palliative care went from 2.55% to 3.27% (p< 0.001) and DNR from 6.31% to 7.7% (p< 0.001). This increase was consistent over time for DNR among all age groups and for palliative care (except in the 50-59 group in PC). PC remained relatively unchanged in all races, but DNR increased in white, Hispanic, and Black patients. All regions saw an increase in DNR and PC (except the Midwest). Using a logistic regression, compared to White patients, Black patients were less likely to have DNR status (OR 0.64[0.64-0.64]), but more likely to be in PC (1.15[1.13-1.17]). Male patients (compared to females) were also less likely to have DNR (0.85[0.85-0.85]) but more likely in PC (1.1[1.1-1.1]). The diagnoses with the highest association with DNR status were lung cancer (2.4[2.4-2.5]), pancreatic cancer (2.4[2.3-2.4]), and sepsis (2.1[2.1-2.1]) (all P < 0.001). The diagnoses most associated with PC were lung cancer (5.3[5.2-5.5]), pancreatic cancer (7.2[6.9-7.5]), colon cancer (5.0[4.8-5.2]), and sepsis (2.8[2.7-2.8]). Overall, mortality and LOS decreased over time between 2016 and 2019, but hospital charges increased. (all p< 0.001) Black race and male gender were associated with higher inpatient mortality (1.12[1.12-1.14]), LOS, and hospital charges. Patients with DNR, PC and DNR, and PC had higher inpatient mortality, LOS, and charges, except patients with DNR only had lower charges than patients without DNR.

Conclusions: In the USA, the proportion of patients with DNR, PC, and DNR with PC increased over time from 2016 to 2019. Overall inpatient mortality and LOS fell, but hospital charges per patient increased. Black patients and males were less likely to have DNR status and had higher inpatient mortality, LOS, and hospital charges. Among all patients, DNR and PC status were associated with higher inpatient mortality and LOS among hospitalized patients.