Charges pre and post do-not-resuscitate orders and outcome in critically ill cancer patients

Purpose: To describe hospital charges for critically ill cancer patients before and after do-not-resuscitate (DNR) orders are written in the surgical intensive care unit (SICU) at a major cancer center. Methods: All consecutive admissions to the SICU at The University of Texas M.D. Anderson Cancer Center from June 1, 1995 to April 30, 1996 were evaluated for the presence of a DNR order written during their SICU stay. Those patients who had a DNR order written prior to their SICU admission were excluded. Total daily hospital charges by hospital department before and after a DNR order was written were tabulated through hospital discharge or death. Results: A total of 1050 charts were reviewed with 23 (2%) patients noted to have DNR orders written. The mean SICU stay before a DNR order was written was 14 (range 1-31) days and the mean post DNR order stay was 11 (range 1-65) days (substantially longer than the length of tay of no DNR order patients). The outcome of these patients included 11 deaths (48%), 5 discharges to the floor (22%), and 7 discharges to hospice or extended care (30%). Withdrawal of support with ensuing death was documented in 8 (34%) cases. The mean cost per day per patient pre DNR order was $6771. The mean total cost pre DNR order was $85,926 (range 5,492-224,996). The mean cost per day post DNR order was $3,982 and the mean total cost post DNR was $42,060 (range 2,383-233,967). Conclusions: Few patients admitted to our SICU have a DNR order written and if written this occurs following a protracted SICU stay. Patients with DNR orders spend a substantial length of time in the SICU. Post DNR daily charges are less than pre-DNR charges. Clinical Implications: Post DNR order patients consume a substantial amount of resources as measured by hospital charges. Few patients have withdrawal of support leading to long hospital stays and substantial total cost. Careful consideration of DNR orders and post DNR care may reduce hospital costs.