A study in the Archives of Surgery compared age-matched patients undergoing the same surgical procedure. Those who had DNRs in place were three times more likely to die in the month following the procedure. The study accounted for the fact that the DNR group was sicker overall, and the difference in mortality rates remained. DNR patients also had more post-surgical complications.

Notably, the study found that the higher risk only occurred after some types of surgeries. For example, exploratory laparotomies had the highest risk for DNR patients, while thighbone fracture repair or appendectomies showed no difference in mortality rates.

The study authors say the results may help doctors advise patients with DNRs on which procedures would be more or less beneficial for them.

A new survey shows most physicians are waiting much longer than was commonly thought to discuss a terminal diagnosis with patients. Is it the right thing to do?

The research, published this month in Cancer, surveyed more than 4,000 doctors who treated cancer patients. They were asked how they would broach discussions of several distinct topics with a hypothetical patient who had 4-6 months left to live, but was still feeling relatively strong and healthy.

The topics for discussion were the prognosis, treatment options (such as DNR orders, hospice care, etc.) and whether the patient wanted to die at home or in the hospital undergoing aggressive treatment.

Generally accepted guidelines are for doctors to open up the discussion of all three once the patient has less than a year to live. The survey showed that in practice, doctors wait much longer.

In fact, 65% of physicians said they would discuss the prognosis right away. But only 44% would immediately bring up resuscitation. The numbers were worse for hospice care (26%) and place of death (only 21%).

Most doctors said they wouldn’t bring up those topics until the patient started to feel worse or there were no further medical treatments to offer.

The researchers didn’t ask the doctors to explain their reasons for postponing the discussion, but it’s safe to say it’s a combination of:

• not wanting to destroy patients’ mental state while they still feel healthy
• some discomfort on the doctors’ part
• not wanting to provide more information than is absolutely required (or asked for).

But the question remains: If doctors wait until the person is already at death’s door, does that really give the patient enough time (and mental clarity) to make the best decisions about treatment options — let alone to get their personal affairs in order?

Some experts say no, citing the fact that while most Americans say they’d prefer to die at home in peace, the vast majority of us die in the hospital, hooked up to a variety of equipment. Delaying the discussion also means some patients may continue treatment with false hopes for a cure that will never come.

On the other hand, many physicians feel that breaking the hardest news too early just saps patients’ energy and can diminish the quality of the time they do have left.

Where do you stand on this difficult question? Share your thoughts in the comments.

The data comes from a recent study by Holly Prigerson at the Dana-Farber Cancer Institute. The study followed 302 patients until their deaths and reviewed both their stated care preferences and the actual care they received.

Granted, the study was small, but some key differences in how white and black patients were treated emerged.

In general, black patients were far more likely to get aggressive end-of-life treatment. But, among patients who had specifically requested aggressive care, white patients were three times more likely to actually receive it.

The opposite was true among patients who stated they did not want aggressive treatment, or who signed DNRs: None of the white patients with DNRs received aggressive treatment, but several of the black patients did.

The report, published in the Journal of Clinical Oncology, suggested that at least some of the disparity in treatment can be explained by less effective communication among the caregivers of the black patients. Black patients were more likely to be transferred to other facilities, and in those cases, communication gaps may have developed.