Background Research on the value of advance directives (ADs) is limited in Oncology critical care.

Aim Determine barriers to ACP and the effect of ADs on cost-of-care (COC) and length-of-stay (LOS) in critical cancer patients.

Methods The COC and LOS of expired ICU patients and all ICU patients were compared. ADs and Do-Not-Resuscitate orders (DNRO) for expired ICU patients were matched to their respective COC, LOS, and cancer diagnosis. The COC of floor and ICU care were compared to determine potential cost savings from ICU avoidance. Providers were surveyed to assess barriers to ACP.

Results 41% of expired ICU patients had an AD. If an AD was present, it was most likely to be a Living Will (LW) with DNRO. Without a DNRO, the COC for patients with ADs was similar to that of patients with no AD. The COC was highest for patients without ADs and lowest for those with LWs with DNRO, despite a longer LOS in this group. Floor care cost on average $2,000 less per day than ICU care. A majority of providers surveyed reported comfort with ACP for inpatients, but not for outpatients.

Discussion/conclusion DNROs were apparently only obtained after longer lengths of stay in expired ICU patients. Timely ADs with DNRO are likely to result in the lowest daily COC for critical patients, with the greatest savings likely resulting from ICU avoidance.

Earlier outpatient implementation of ACP will likely enhance value in critical cancer patients and opportunities to better understand and overcome barriers exist.