End-of-life emergency medical service transport among patients with terminal cancer, by cardiopulmonary arrest status: A nationwide mortality follow-back survey

End-of-life emergency medical service transport among patients with terminal cancer, by cardiopulmonary arrest status: A nationwide mortality follow-back survey | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article End-of-life emergency medical service transport among patients with terminal cancer, by cardiopulmonary arrest status: A nationwide mortality follow-back survey Yoko Nakazawa, Mitsunori Miyashita, Tatsuya Morita, Yoshiyuki Kizawa, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7250687/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Jan, 2026 Read the published version in Supportive Care in Cancer → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose Emergency medical service (EMS) transport during the terminal stage of cancer may result in cardiopulmonary arrest (CPA) and resuscitation, which may not align with patient preferences. The characteristics and care experiences of patients transported in CPA have not been well studied in Japan. This study aimed to describe the characteristics and end-of-life (EOL) care experiences of patients with terminal cancer with and without CPA at EMS transport. Methods We conducted a secondary analysis of a nationwide mortality follow-back survey (2019–2020), using structured questionnaires completed by bereaved family members and linked to death certificates. We analyzed 4,939 patients with terminal cancer who were transported by EMS in the final month of life and died in hospitals between 2017 and 2018. Patients were categorized based on their CPA status at EMS transport. Results Among 4,939 patients, 178 (3.6%) had CPA. The CPA group had more lung cancer (+ 8.0%) and less colorectal (− 7.2%) and hepatobiliary/pancreatic cancers (− 8.2%). They were less likely to have reported do-not-resuscitate status (55.9% vs. 92.6%), had in resuscitation discussions (46.5% vs. 62.1%), or EOL discussions with family (39.5% vs. 50.8%). Out-of-pocket expenses were lower (41.2% under ¥100,000 vs. 21.7%). They reported lower symptom burden and slightly higher perceived death quality (+ 5.0 points). Conclusions Patients transported in CPA experienced fewer EOL discussions and preparedness, socioeconomic disparities, and distinct perceptions of death quality. These findings emphasize the need to enhance advance care planning communication and emergency preparedness in EOL cancer care. Cardiopulmonary Arrest Emergency Medical Services Neoplasms Terminal Care Palliative Care Advance Care Planning Resuscitation Bereavement Figures Figure 1 Figure 2 Figure 3 Introduction Emergency medical service (EMS) transport at the end of life (EOL) is a critical clinical event in cancer care, particularly for patients with advanced disease. Although EMS transport is often necessary, it may involve interventions such as cardiopulmonary arrest (CPA) management and resuscitation, which are sometimes not aligned with patient preferences [ 1 , 2 ]. Resuscitation efforts during the final moments of life may cause emotional distress for patients and their families and potentially compromise the quality of death and dying [ 3 , 4 ]. Despite the growing emphasis on goal-concordant care, previous research has indicated that a proportion of terminally ill patients still undergo resuscitation during EMS transport at the time of death [ 5 – 7 ]. Advance care planning (ACP), which includes communication about resuscitation preferences and EOL care goals, is promoted in many countries to reduce potentially non-beneficial interventions [ 8 ]. However, in Japan, a substantial proportion of patients still undergo EMS transport near the EOL, often without prior care discussions or clear communication of patient preferences [ 9 – 11 ]. Moreover, resuscitation decisions are frequently delayed, and ACP remains underdeveloped [ 12 – 14 ]. Previous studies have primarily focused on aggressive EOL interventions, such as intensive care unit (ICU) admission or late chemotherapy [ 11 , 12 ]. However, limited research has examined the characteristics, care contexts, and communication patterns surrounding EMS transport in the final stages of life, particularly in patients with CPA. However, nationally representative data on this topic are limited. This study aimed to describe the characteristics of patients with terminal cancer, with and without CPA, during EMS transport before death. Using data from a nationwide mortality follow-back survey based on bereaved family reports [ 15 ], we examined the clinical, socioeconomic, and communication-related characteristics according to CPA status, providing descriptive insights to inform future practices and policies. Methods Study Design This observational descriptive study used secondary data from a nationwide mortality follow-back survey conducted in Japan. We described the clinical, socioeconomic, and EOL discussion-related characteristics of patients with terminal cancer transported by EMS before death, with a focus on CPA status. Data Source The original study used data from a population-based nationwide bereavement survey linked to death certificates conducted between 2019 and 2020 [ 16 ]. Stratified random sampling was performed for the five major causes of death: cancer, heart disease, cerebrovascular disease, pneumonia, and renal failure. Eligible decedents were aged ≥ 20 years and had died between 2017 and 2018 in a hospital, long-term care facility, or at home. Questionnaires were mailed to bereaved family members 13 to 25 months after death to assess EOL care experiences. The survey details have been reported previously [ 15 ]. Participants This study focused on patients with cancer who received EMS transport prior to death. Although the original survey included multiple causes of death, this study analyzed only cancer cases. Of the 54,617 returned responses (response rate: 56.7%), 9,241 (16.9%) indicated that the patient had been transported by EMS within 1 month before death. From these, 4,939 patients were included based on the following criteria: 1) more than 1 month between diagnosis and death, and 2) hospital death as recorded on the death certificate. Based on family reports, patients with CPA at the time of EMS transport who received resuscitation were classified into the CPA group, whereas all others were classified into the non-CPA group. Figure 1 shows the sample selection process. [Insert Fig. 1 here] Measurements Primary Variable of Interest The primary descriptive variable was the characteristics of patients with cancer who experienced CPA during EMS transport before death and received resuscitation. Bereaved family members reported whether the patients had experienced CPA and received EMS transport in the final month of life. Patient Characteristics We descriptively examined the range of patient background characteristics regarding CPA status. Age, sex, and cancer type were obtained from the death certificate records. Family-reported variables included time from cancer diagnosis to death, functional status during the last month of life, history of dementia, cohabitation status, household income in the last year of life, out-of-pocket medical and care expenses in the final month, and the relationship between the deceased and the responding family member. Patient EOL Care and Experiences Bereaved family members reported the use of home medical care, long-term care, code status, prognostic awareness, EOL discussions, quality of death, quality of EOL care, and distressing symptoms. Prognostic awareness was assessed using questions adapted from a previous study [ 17 ]. Family members rated the patient’s understanding of their condition during the final month. Responses were: “unaware of illness,” “not seriously ill,” “seriously ill but not terminal,” “seriously ill and terminal,” or “unknown.” The “Seriously ill but not terminal" option indicated accurate prognostic awareness. EOL Discussions about code status (patient-physician) and EOL care (patient–family) were assessed using the same scale [ 18 , 19 ]. Responses were: “absolutely disagree,” disagree, “agree,” absolutely agree, “not applicable,” or “unknown”; “agree” or “absolutely agree” were considered affirmative. Quality of EOL care was measured using the 10-item Care Evaluation Scale (range, 10–60) rated on a 6-point Likert scale (1 = absolutely disagree to 6 = absolutely agree), with higher scores indicating better care [ 20 ]. Quality of death was measured using the 10-item Good Death Inventory (range, 10–70) and a 7-point Likert scale (1–7), with higher scores indicating better outcomes [ 21 ]. Symptom burden during the final week was reported by the bereaved family members using the Japanese version of the Memorial Symptom Assessment Scale–Short Form [ 22 ]. Seven symptoms (e.g., pain and dyspnea) were rated on a 5-point scale (0 = not at all to 4 = very much). Scores ≥ 4 were defined as severe. Family EOL Experiences Family members reported bedside presence in the final week, prognostic awareness, discussions with physicians regarding resuscitation preferences, caregiver burden, physical and mental health, and post-bereavement psychological symptoms. Prognostic awareness and discussions with physicians were assessed using the same response options as those used for the patients [ 17 ]. Awareness refers to how family members perceived the patient’s prognosis, and discussions capture whether the family and physician had discussed the code status. Caregiver burden was measured using four items from the Caregiver Consequence Inventory to assess time, physical, mental, and financial strain [ 23 ]. Overall burden and personal growth were rated on a 7-point Likert scale (1 = strongly disagree to 7 = strongly agree), with higher scores indicating greater burden or growth. Self-rated physical and mental health during the patient’s final week was assessed on a 4-point Likert scale (“very poor” to “good”); responses of “very poor” or “poor” indicated poor health. Depressive symptoms were assessed 1–2 years after bereavement using the Japanese version of the PHQ-2 [ 24 ]. Scores ranged from 0 (not at all) to 3 (nearly every day), with total scores ≥ 3 indicating depression. Grief symptoms were measured using two items from the Japanese version of the Prolonged Grief Disorder scale [ 25 ]. The items assessed yearning and emotional pain on a 5-point scale (1 = not at all to 5 = several times daily). Grief was considered present if either item was rated four or higher. Assessments were performed 1–2 years after bereavement. Statistical Analyses This study employed a descriptive-analytical approach to examine the differences in patient characteristics according to CPA status at the time of EMS transport, as reported by bereaved family members. We summarised the demographic and clinical variables according to CPA status using counts (proportions) and means with 95% confidence intervals (CI). Group comparisons were conducted using the chi-square test for categorical variables and the t-test for continuous variables. In addition, we calculated the absolute differences in proportions or means between groups, along with 95% CIs, to facilitate a descriptive interpretation of the findings. In keeping with the descriptive nature of the study, no multivariable modelling or covariate adjustment was performed. Analyses were based on available case data without the imputation of missing values. These findings should be interpreted as observational and descriptive, without causal inferences. All analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC, USA). Results Of the 54,617 patients with cancer reported by bereaved family members, 9,241 (16.9%) received emergency medical transport during the final month of life. Among these, 4,939 patients met all inclusion criteria—death occurred more than 1 month after diagnosis and in a hospital—and were included in the final analytical sample (Fig. 1 ). Among them, 178 (3.6%, 95% CI, 3.1–4.1%) were reported to have experienced CPA during emergency transport and received resuscitation. Patient Characteristics The patient characteristics according to CPA status are presented in Table 1. Absolute differences in these characteristics are presented in Supplementary Table 1. Lung cancer was reported in 29.8% of patients with CPA (95% CI, 23.1 to 36.5) and 21.7% of non-CPA patients (95% CI, 20.6 to 22.9), a difference of + 8.0 points (95% CI, 1.2 to 14.9). Colorectal cancer was reported in 5.6% of patients with CPA (95% CI, 2.2 to 9.0) and 12.8% of non-CPA patients (95% CI, 11.9 to 13.8), a difference of -7.2 points (95% CI, -10.7 to -3.7). Hepatobiliary or pancreatic cancers were observed in 14.0% of patients with CPA (95% CI: 8.8 to 19.2) versus 22.2% in non-CPA (95% CI, 21.1 to 23.4), a difference of -8.2 points (95% CI, -13.4 to -3.0). A total of 9.1% of patients with CPA died within 2–3 months of diagnosis (95% CI, 4.9 to 13.4), compared to 15.4% in non-CPA (95% CI, 14.4 to 16.5), a difference of -6.3 points (95% CI, -10.7 to -1.9). Out-of-pocket expenses under ¥100,000 in the final month of life were reported in 41.2% of patients with CPA (95% CI, 33.3 to 49.1) versus 21.7% of non-CPA patients (95% CI, 20.5 to 23.0), a difference of + 19.5 points (95% CI, 11.5 to 27.5). The CPA group also had a lower proportion of patients in the highest household income category (≥ 6 million yen/year). [Insert Table 1 here] Patient EOL Care and Experiences The differences in patient EOL care and experiences according to CPA status during EMS transport are shown in Fig. 2 . Absolute differences in these end-of-life outcomes are provided in Supplementary Table 2. Home medical care services were used by 28.6% of the total sample (95% CI, 27.2 to 30.0). Do not resuscitate (DNR) status was reported in 55.9% of the CPA group (95% CI, 44.1 to 67.7) and 92.6% of the non-CPA group (95% CI, 91.6 to 93.5), a difference of -36.7 points (95% CI, -49.4 to -25.7). Resuscitation discussions with physicians were reported in 46.5% of patients with CPA (95% CI, 36.0 to 57.1) and 62.1% of non-CPA patients (95% CI, 60.2 to 63.9), a difference of -15.6 points (95% CI, -26.3 to -4.9). Discussions with family about EOL care occurred in 39.5% of patients with CPA and 50.8% of non-CPA patients, a difference of -11.3 points (95% CI, -19.9 to -2.7). The mean quality-of-death score was 48.7 in the CPA group (95% CI, 47.0 to 50.5) and 43.7 in the non-CPA group (95% CI, 43.3 to 44.1), a difference of + 5.0 points (95% CI, 3.3 to 6.8). Symptom burden was less frequently reported in the CPA group, particularly for symptoms such as loss of appetite and difficulty swallowing. [Insert Fig. 2 here] Family EOL Experiences The differences in family EOL care and experiences according to CPA status during EMS transport are shown in Fig. 3 . Absolute differences in these end-of-life outcomes are provided in Supplementary Table 2. Family-physician discussions about resuscitation were reported by 41.7% of CPA cases (95% CI, 33.2 to 50.3) and 68.9% of non-CPA cases (95% CI, 67.4 to 70.4), a difference of -27.2 points (95% CI, -35.9 to -18.5). Compared to the non-CPA group, CPA families were more often always present at the bedside during the final week (12.3 points, 95% CI, 6.2 to 18.4), and less often only sometimes present (-12.6 points, 95% CI, -17.7 to -7.5). [Insert Fig. 3 here] Discussions This descriptive study is the first to summarize patterns of CPA during EMS transport among patients with terminal cancer in Japan, using data from a population-based national bereavement survey. The CPA group exhibited several distinct patterns. First, a higher proportion of patients had lung cancer, whereas lower proportions had colorectal, hepatobiliary, and pancreatic cancers. Second, patients with longer survival since diagnosis were more frequently observed in this group. Third, this group included fewer patients from higher-income households and a greater proportion with lower out-of-pocket medical expenses during the final month of life. Fourth, this group had lower rates of discussions about resuscitation with physicians and family members, as well as lower rates of family–physician discussions about resuscitation, despite many having expressed DNR preferences. Bereaved family members also reported a slightly higher perceived quality of death and less symptom burden. Clinical Characteristics of Patients With CPA In lung cancer, complications such as haemoptysis or respiratory failure can occur suddenly and may be fatal [ 26 ], leaving little time for advanced discussions or emergency planning. In contrast, colorectal and hepatobiliary cancers often follow a more predictable course, allowing for anticipatory care and symptom management that may help prevent acute deterioration [ 27 , 28 ]. The variation in CPA transport proportions across cancer types underscores the value of timely ACP aligned with disease trajectory [ 29 ]. Additionally, the higher proportion of long-term survivors in the CPA group may reflect psychological factors, such as prognostic optimism and cultural tendencies in Japan to avoid death-related discussions [ 30 , 31 ]. Prognostic uncertainty, rather than proximity to death, may prompt timely EOL discussions [ 8 , 29 ]. Socioeconomic Disparities and Access to EOL Care The higher proportion of lower-income households and patients with lower out-of-pocket medical expenses in the CPA group suggests potential disparities in access to comprehensive EOL care [ 32 ]. Patients with greater financial resources may have better access to services, allowing for active symptom management and planned care transitions, which could help reduce the need for crisis-driven emergency transport [ 32 ]. These findings align with existing concerns about equity in Japan’s healthcare system. Despite universal health insurance coverage, socioeconomic status may influence the quality and comprehensiveness of EOL care [ 33 ]. Addressing these disparities requires expanding community-based programs and providing additional support for vulnerable populations [ 34 ]. EOL Discussions, Symptoms, and Perceived Death Quality In the CPA group, lower rates of discussions about resuscitation with physicians and family members were observed, despite many patients expressing DNR preferences. This discrepancy highlights the need for specific action-oriented communication to ensure that emergency care aligns with patient preferences. This is consistent with previous literature emphasizing the importance of addressing treatment decisions and care goals directly [ 8 , 29 ]. In the Japanese context, families often play a central role in medical decision-making, and including family members in these discussions is particularly important [ 30 ]. Interestingly, patients in the CPA group were reported to have a higher perceived quality of death and fewer reported symptom burdens, particularly loss of appetite and difficulty swallowing. These findings suggest that patients with a relatively stable clinical course who experience a sudden death may be perceived by bereaved family members as having had a "good death" [ 21 ]. However, such perceptions may also be influenced by the emotional context surrounding the unexpected nature of CPA, potentially affecting retrospective evaluations of symptoms and the perceived quality of death [ 35 ]. Clinical Implications This study reinforces the importance of early structured ACP and family-centred communication, particularly for patients at risk of sudden deterioration at home. Policy efforts should also address the gaps in emergency preparedness and equitable access to EOL care, including enhanced support for home-based and community palliative services. Future studies should also focus on identifying optimal strategies to improve ACP and emergency planning for high-risk patients. Integrating qualitative insights may advance intervention development and clarify the decision-making dynamics around EMS and resuscitation. Strengths and Limitations Previous studies on EMS use and aggressive EOL care in patients with cancer have largely focused on ICU admission, late chemotherapy, and place of death [ 11 , 12 ]. Few studies have described the specific characteristics of patients having CPA during emergency transport or explored the relationship between communication practices and EOL experiences. This study provides new insights into disease-specific patterns, socioeconomic disparities, and EOL communication practices. This study had several limitations that should be considered when interpreting the findings. First, the data relied on retrospective reports from bereaved family members, which may have been subject to recall bias. Proxy accounts may not fully reflect the actual experiences or preferences of patients, especially concerning EOL care discussions. The time lag between the patient’s death and the survey (13–25 months) may have contributed to this recall bias. Second, key variables such as CPA status at the time of emergency transport and the presence or absence of resuscitation were based on family-reported data and may not align precisely with clinical records or standardized definitions. In addition, the timing of DNR documentation and EOL care discussions in relation to the cardiac arrest event was not assessed, limiting interpretation of their sequence. Third, although the analytic outcome in this study was whether patients in CPA were transported by EMS near the EOL, the appropriateness or timing of EMS use and whether it reflected patient preferences or clinical needs could not be assessed. Finally, because this study employed a cross-sectional design, any observed differences should be interpreted descriptively rather than causally. Future research should benefit from prospective data collection, triangulation with medical records, and mixed-method approaches, including qualitative studies exploring the decision-making processes and communication dynamics surrounding emergency care and resuscitation. Declarations Competing interests The authors declare no competing interests. Ethics approval This study was approved by the Institutional Review Board of the National Cancer Center of Japan (reference number 2017 − 346; approved on June 5, 2018) and conducted in accordance with the Ethical Guidelines for Medical and Biological Research Involving Human Subjects in Japan. Consent Consent for participation was obtained by completing and returning questionnaires. Data, material, and/or code availability The data of decedents are not publicly available due to restrictions on data sharing. Funding This study was supported by a Grant-in-Aid for Scientific Research from the Ministry of Health, Labor and Welfare, Japan (grant number 24EA1005). Author Contribution Yoko Nakazawa: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing—original draft. Mitsunori Miyashita: Conceptualization, Methodology, Supervision, Writing—review & editing. Tatsuya Morita: Conceptualization, Methodology, Supervision, Writing—review & editing. Yasuyuki Okumura: Formal analysis, Methodology, Supervision, Writing—review & editing. Yoshiyuki Kizawa: Conceptualization, Methodology, Supervision, Writing—review & editing. Shohei Kawagoe: Supervision, Writing—review & editing. Hiroshi Yamamoto: Supervision, Writing—review & editing. Emi Takeuchi: Investigation, Writing—review & editing. Risa Yamazaki: Investigation, Writing—review & editing. Asao Ogawa: Conceptualization, Funding acquisition, Project administration, Writing—review & editing. 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Supplementary Files c16table1250716.xlsx c16supple250716.xlsx Cite Share Download PDF Status: Published Journal Publication published 13 Jan, 2026 Read the published version in Supportive Care in Cancer → Version 1 posted Editorial decision: Revision requested 05 Nov, 2025 Reviews received at journal 27 Oct, 2025 Reviews received at journal 18 Oct, 2025 Reviewers agreed at journal 04 Oct, 2025 Reviewers agreed at journal 29 Sep, 2025 Reviewers invited by journal 29 Sep, 2025 Editor assigned by journal 02 Sep, 2025 Submission checks completed at journal 31 Jul, 2025 First submitted to journal 30 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7250687","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":527199402,"identity":"3df97879-7474-4bb1-835c-bda0c1793792","order_by":0,"name":"Yoko Nakazawa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAz0lEQVRIiWNgGAWjYHACZjDJD+MyNhCrRRKmkngtBgeIdZXB7ebHBj/+2CVuvt388APDLxsG5tkErDG4c8w4sYcnOXEbkCHB2JfGwDiHgH0GNxKMD/BIMOduu5HDxsDYc5iBcUYCIS3pnw/+MajP3TyDeC05xsk8CYdzN0gAtTD8IEKL5I2cYmOZA8frZ9xIM5ZIbEjjIegXvhvpmyXf/Kk25p+R/PDDhz82coaEQkwBxcjENgYewxn4dTDIoxr5BygiQUDLKBgFo2AUjDgAAAJCR1JQKN/fAAAAAElFTkSuQmCC","orcid":"","institution":"National Cancer Center","correspondingAuthor":true,"prefix":"","firstName":"Yoko","middleName":"","lastName":"Nakazawa","suffix":""},{"id":527199403,"identity":"a534551a-5509-4c86-a13d-434bed674dcf","order_by":1,"name":"Mitsunori Miyashita","email":"","orcid":"","institution":"Tohoku University","correspondingAuthor":false,"prefix":"","firstName":"Mitsunori","middleName":"","lastName":"Miyashita","suffix":""},{"id":527199404,"identity":"d9e27d58-5cfb-47e0-ba1a-c1a9876fd731","order_by":2,"name":"Tatsuya 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3","display":"","copyAsset":false,"role":"figure","size":34931,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"c16fig3250730.png","url":"https://assets-eu.researchsquare.com/files/rs-7250687/v1/3cf03feb61397bdb4d4ec865.png"},{"id":100617202,"identity":"528106ab-0dd0-4f8f-8349-b55b97e2c0cc","added_by":"auto","created_at":"2026-01-19 17:49:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":709442,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7250687/v1/a28087c3-0b65-4085-884a-187212b29592.pdf"},{"id":93339492,"identity":"ce3095ee-1567-4676-bdb5-e57cc246905f","added_by":"auto","created_at":"2025-10-12 14:26:33","extension":"xlsx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":17493,"visible":true,"origin":"","legend":"","description":"","filename":"c16table1250716.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7250687/v1/bed357397e4e6d09fc5c2bbc.xlsx"},{"id":93340727,"identity":"c75a5a2d-8463-4ed6-a813-0d28d145179e","added_by":"auto","created_at":"2025-10-12 14:34:33","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":21836,"visible":true,"origin":"","legend":"","description":"","filename":"c16supple250716.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7250687/v1/e1371a7fec458acfe5bb5b57.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"End-of-life emergency medical service transport among patients with terminal cancer, by cardiopulmonary arrest status: A nationwide mortality follow-back survey","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEmergency medical service (EMS) transport at the end of life (EOL) is a critical clinical event in cancer care, particularly for patients with advanced disease. Although EMS transport is often necessary, it may involve interventions such as cardiopulmonary arrest (CPA) management and resuscitation, which are sometimes not aligned with patient preferences [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eResuscitation efforts during the final moments of life may cause emotional distress for patients and their families and potentially compromise the quality of death and dying [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Despite the growing emphasis on goal-concordant care, previous research has indicated that a proportion of terminally ill patients still undergo resuscitation during EMS transport at the time of death [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e–\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAdvance care planning (ACP), which includes communication about resuscitation preferences and EOL care goals, is promoted in many countries to reduce potentially non-beneficial interventions [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, in Japan, a substantial proportion of patients still undergo EMS transport near the EOL, often without prior care discussions or clear communication of patient preferences [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e–\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Moreover, resuscitation decisions are frequently delayed, and ACP remains underdeveloped [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e–\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePrevious studies have primarily focused on aggressive EOL interventions, such as intensive care unit (ICU) admission or late chemotherapy [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, limited research has examined the characteristics, care contexts, and communication patterns surrounding EMS transport in the final stages of life, particularly in patients with CPA. However, nationally representative data on this topic are limited.\u003c/p\u003e\u003cp\u003eThis study aimed to describe the characteristics of patients with terminal cancer, with and without CPA, during EMS transport before death. Using data from a nationwide mortality follow-back survey based on bereaved family reports [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], we examined the clinical, socioeconomic, and communication-related characteristics according to CPA status, providing descriptive insights to inform future practices and policies.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003eStudy Design\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis observational descriptive study used secondary data from a nationwide mortality follow-back survey conducted in Japan. We described the clinical, socioeconomic, and EOL discussion-related characteristics of patients with terminal cancer transported by EMS before death, with a focus on CPA status.\u003c/p\u003e\u003cp\u003e\u003cem\u003eData Source\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe original study used data from a population-based nationwide bereavement survey linked to death certificates conducted between 2019 and 2020 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Stratified random sampling was performed for the five major causes of death: cancer, heart disease, cerebrovascular disease, pneumonia, and renal failure.\u003c/p\u003e\u003cp\u003eEligible decedents were aged ≥ 20 years and had died between 2017 and 2018 in a hospital, long-term care facility, or at home. Questionnaires were mailed to bereaved family members 13 to 25 months after death to assess EOL care experiences. The survey details have been reported previously [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003eParticipants\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis study focused on patients with cancer who received EMS transport prior to death. Although the original survey included multiple causes of death, this study analyzed only cancer cases. Of the 54,617 returned responses (response rate: 56.7%), 9,241 (16.9%) indicated that the patient had been transported by EMS within 1 month before death. From these, 4,939 patients were included based on the following criteria: 1) more than 1 month between diagnosis and death, and 2) hospital death as recorded on the death certificate.\u003c/p\u003e\u003cp\u003eBased on family reports, patients with CPA at the time of EMS transport who received resuscitation were classified into the CPA group, whereas all others were classified into the non-CPA group. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the sample selection process.\u003c/p\u003e\u003cp\u003e[Insert Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here]\u003c/p\u003e\u003cp\u003e\u003cem\u003eMeasurements\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003ePrimary Variable of Interest\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe primary descriptive variable was the characteristics of patients with cancer who experienced CPA during EMS transport before death and received resuscitation. Bereaved family members reported whether the patients had experienced CPA and received EMS transport in the final month of life.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePatient Characteristics\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWe descriptively examined the range of patient background characteristics regarding CPA status. Age, sex, and cancer type were obtained from the death certificate records. Family-reported variables included time from cancer diagnosis to death, functional status during the last month of life, history of dementia, cohabitation status, household income in the last year of life, out-of-pocket medical and care expenses in the final month, and the relationship between the deceased and the responding family member.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePatient EOL Care and Experiences\u003c/em\u003e\u003c/p\u003e\u003cp\u003eBereaved family members reported the use of home medical care, long-term care, code status, prognostic awareness, EOL discussions, quality of death, quality of EOL care, and distressing symptoms.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePrognostic awareness\u003c/b\u003e was assessed using questions adapted from a previous study [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Family members rated the patient’s understanding of their condition during the final month. Responses were: “unaware of illness,” “not seriously ill,” “seriously ill but not terminal,” “seriously ill and terminal,” or “unknown.” The “Seriously ill but not terminal\" option indicated accurate prognostic awareness.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEOL Discussions\u003c/b\u003e about code status (patient-physician) and EOL care (patient–family) were assessed using the same scale [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Responses were: “absolutely disagree,” disagree, “agree,” absolutely agree, “not applicable,” or “unknown”; “agree” or “absolutely agree” were considered affirmative.\u003c/p\u003e\u003cp\u003e\u003cb\u003eQuality of EOL care\u003c/b\u003e was measured using the 10-item Care Evaluation Scale (range, 10–60) rated on a 6-point Likert scale (1 = absolutely disagree to 6 = absolutely agree), with higher scores indicating better care [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eQuality of death\u003c/b\u003e was measured using the 10-item Good Death Inventory (range, 10–70) and a 7-point Likert scale (1–7), with higher scores indicating better outcomes [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eSymptom burden\u003c/b\u003e during the final week was reported by the bereaved family members using the Japanese version of the Memorial Symptom Assessment Scale–Short Form [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Seven symptoms (e.g., pain and dyspnea) were rated on a 5-point scale (0 = not at all to 4 = very much). Scores ≥ 4 were defined as severe.\u003c/p\u003e\u003cp\u003e\u003cem\u003eFamily EOL Experiences\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFamily members reported bedside presence in the final week, prognostic awareness, discussions with physicians regarding resuscitation preferences, caregiver burden, physical and mental health, and post-bereavement psychological symptoms.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePrognostic awareness and discussions\u003c/b\u003e with physicians were assessed using the same response options as those used for the patients [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Awareness refers to how family members perceived the patient’s prognosis, and discussions capture whether the family and physician had discussed the code status.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCaregiver burden\u003c/b\u003e was measured using four items from the Caregiver Consequence Inventory to assess time, physical, mental, and financial strain [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Overall burden and personal growth were rated on a 7-point Likert scale (1 = strongly disagree to 7 = strongly agree), with higher scores indicating greater burden or growth.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSelf-rated physical and mental health\u003c/b\u003e during the patient’s final week was assessed on a 4-point Likert scale (“very poor” to “good”); responses of “very poor” or “poor” indicated poor health.\u003c/p\u003e\u003cp\u003e\u003cb\u003eDepressive symptoms\u003c/b\u003e were assessed 1–2 years after bereavement using the Japanese version of the PHQ-2 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Scores ranged from 0 (not at all) to 3 (nearly every day), with total scores ≥ 3 indicating depression.\u003c/p\u003e\u003cp\u003e\u003cb\u003eGrief symptoms\u003c/b\u003e were measured using two items from the Japanese version of the Prolonged Grief Disorder scale [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The items assessed yearning and emotional pain on a 5-point scale (1 = not at all to 5 = several times daily). Grief was considered present if either item was rated four or higher. Assessments were performed 1–2 years after bereavement.\u003c/p\u003e\u003cp\u003e\u003cem\u003eStatistical Analyses\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis study employed a descriptive-analytical approach to examine the differences in patient characteristics according to CPA status at the time of EMS transport, as reported by bereaved family members. We summarised the demographic and clinical variables according to CPA status using counts (proportions) and means with 95% confidence intervals (CI).\u003c/p\u003e\u003cp\u003eGroup comparisons were conducted using the chi-square test for categorical variables and the t-test for continuous variables. In addition, we calculated the absolute differences in proportions or means between groups, along with 95% CIs, to facilitate a descriptive interpretation of the findings.\u003c/p\u003e\u003cp\u003eIn keeping with the descriptive nature of the study, no multivariable modelling or covariate adjustment was performed. Analyses were based on available case data without the imputation of missing values. These findings should be interpreted as observational and descriptive, without causal inferences. All analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 54,617 patients with cancer reported by bereaved family members, 9,241 (16.9%) received emergency medical transport during the final month of life. Among these, 4,939 patients met all inclusion criteria\u0026mdash;death occurred more than 1 month after diagnosis and in a hospital\u0026mdash;and were included in the final analytical sample (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Among them, 178 (3.6%, 95% CI, 3.1\u0026ndash;4.1%) were reported to have experienced CPA during emergency transport and received resuscitation.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePatient Characteristics\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe patient characteristics according to CPA status are presented in Table\u0026nbsp;1. Absolute differences in these characteristics are presented in Supplementary Table\u0026nbsp;1.\u003c/p\u003e\u003cp\u003eLung cancer was reported in 29.8% of patients with CPA (95% CI, 23.1 to 36.5) and 21.7% of non-CPA patients (95% CI, 20.6 to 22.9), a difference of +\u0026thinsp;8.0 points (95% CI, 1.2 to 14.9). Colorectal cancer was reported in 5.6% of patients with CPA (95% CI, 2.2 to 9.0) and 12.8% of non-CPA patients (95% CI, 11.9 to 13.8), a difference of -7.2 points (95% CI, -10.7 to -3.7). Hepatobiliary or pancreatic cancers were observed in 14.0% of patients with CPA (95% CI: 8.8 to 19.2) versus 22.2% in non-CPA (95% CI, 21.1 to 23.4), a difference of -8.2 points (95% CI, -13.4 to -3.0).\u003c/p\u003e\u003cp\u003eA total of 9.1% of patients with CPA died within 2\u0026ndash;3 months of diagnosis (95% CI, 4.9 to 13.4), compared to 15.4% in non-CPA (95% CI, 14.4 to 16.5), a difference of -6.3 points (95% CI, -10.7 to -1.9). Out-of-pocket expenses under \u0026yen;100,000 in the final month of life were reported in 41.2% of patients with CPA (95% CI, 33.3 to 49.1) versus 21.7% of non-CPA patients (95% CI, 20.5 to 23.0), a difference of +\u0026thinsp;19.5 points (95% CI, 11.5 to 27.5). The CPA group also had a lower proportion of patients in the highest household income category (\u0026ge;\u0026thinsp;6\u0026nbsp;million yen/year).\u003c/p\u003e\u003cp\u003e[Insert Table\u0026nbsp;1 here]\u003c/p\u003e\u003cp\u003e\u003cem\u003ePatient EOL Care and Experiences\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe differences in patient EOL care and experiences according to CPA status during EMS transport are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Absolute differences in these end-of-life outcomes are provided in Supplementary Table\u0026nbsp;2.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e Home medical care services were used by 28.6% of the total sample (95% CI, 27.2 to 30.0). Do not resuscitate (DNR) status was reported in 55.9% of the CPA group (95% CI, 44.1 to 67.7) and 92.6% of the non-CPA group (95% CI, 91.6 to 93.5), a difference of -36.7 points (95% CI, -49.4 to -25.7).\u003c/p\u003e\u003cp\u003eResuscitation discussions with physicians were reported in 46.5% of patients with CPA (95% CI, 36.0 to 57.1) and 62.1% of non-CPA patients (95% CI, 60.2 to 63.9), a difference of -15.6 points (95% CI, -26.3 to -4.9). Discussions with family about EOL care occurred in 39.5% of patients with CPA and 50.8% of non-CPA patients, a difference of -11.3 points (95% CI, -19.9 to -2.7). The mean quality-of-death score was 48.7 in the CPA group (95% CI, 47.0 to 50.5) and 43.7 in the non-CPA group (95% CI, 43.3 to 44.1), a difference of +\u0026thinsp;5.0 points (95% CI, 3.3 to 6.8). Symptom burden was less frequently reported in the CPA group, particularly for symptoms such as loss of appetite and difficulty swallowing.\u003c/p\u003e\u003cp\u003e[Insert Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e here]\u003c/p\u003e\u003cp\u003e\u003cem\u003eFamily EOL Experiences\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe differences in family EOL care and experiences according to CPA status during EMS transport are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Absolute differences in these end-of-life outcomes are provided in Supplementary Table\u0026nbsp;2.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFamily-physician discussions about resuscitation were reported by 41.7% of CPA cases (95% CI, 33.2 to 50.3) and 68.9% of non-CPA cases (95% CI, 67.4 to 70.4), a difference of -27.2 points (95% CI, -35.9 to -18.5). Compared to the non-CPA group, CPA families were more often always present at the bedside during the final week (12.3 points, 95% CI, 6.2 to 18.4), and less often only sometimes present (-12.6 points, 95% CI, -17.7 to -7.5).\u003c/p\u003e\u003cp\u003e[Insert Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e here]\u003c/p\u003e"},{"header":"Discussions","content":"\u003cp\u003eThis descriptive study is the first to summarize patterns of CPA during EMS transport among patients with terminal cancer in Japan, using data from a population-based national bereavement survey.\u003c/p\u003e\u003cp\u003eThe CPA group exhibited several distinct patterns. First, a higher proportion of patients had lung cancer, whereas lower proportions had colorectal, hepatobiliary, and pancreatic cancers. Second, patients with longer survival since diagnosis were more frequently observed in this group. Third, this group included fewer patients from higher-income households and a greater proportion with lower out-of-pocket medical expenses during the final month of life. Fourth, this group had lower rates of discussions about resuscitation with physicians and family members, as well as lower rates of family\u0026ndash;physician discussions about resuscitation, despite many having expressed DNR preferences. Bereaved family members also reported a slightly higher perceived quality of death and less symptom burden.\u003c/p\u003e\u003cp\u003e\u003cem\u003eClinical Characteristics of Patients With CPA\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn lung cancer, complications such as haemoptysis or respiratory failure can occur suddenly and may be fatal [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], leaving little time for advanced discussions or emergency planning. In contrast, colorectal and hepatobiliary cancers often follow a more predictable course, allowing for anticipatory care and symptom management that may help prevent acute deterioration [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The variation in CPA transport proportions across cancer types underscores the value of timely ACP aligned with disease trajectory [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAdditionally, the higher proportion of long-term survivors in the CPA group may reflect psychological factors, such as prognostic optimism and cultural tendencies in Japan to avoid death-related discussions [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Prognostic uncertainty, rather than proximity to death, may prompt timely EOL discussions [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003eSocioeconomic Disparities and Access to EOL Care\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe higher proportion of lower-income households and patients with lower out-of-pocket medical expenses in the CPA group suggests potential disparities in access to comprehensive EOL care [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Patients with greater financial resources may have better access to services, allowing for active symptom management and planned care transitions, which could help reduce the need for crisis-driven emergency transport [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThese findings align with existing concerns about equity in Japan\u0026rsquo;s healthcare system. Despite universal health insurance coverage, socioeconomic status may influence the quality and comprehensiveness of EOL care [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Addressing these disparities requires expanding community-based programs and providing additional support for vulnerable populations [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003eEOL Discussions, Symptoms, and Perceived Death Quality\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn the CPA group, lower rates of discussions about resuscitation with physicians and family members were observed, despite many patients expressing DNR preferences. This discrepancy highlights the need for specific action-oriented communication to ensure that emergency care aligns with patient preferences. This is consistent with previous literature emphasizing the importance of addressing treatment decisions and care goals directly [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In the Japanese context, families often play a central role in medical decision-making, and including family members in these discussions is particularly important [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eInterestingly, patients in the CPA group were reported to have a higher perceived quality of death and fewer reported symptom burdens, particularly loss of appetite and difficulty swallowing. These findings suggest that patients with a relatively stable clinical course who experience a sudden death may be perceived by bereaved family members as having had a \"good death\" [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, such perceptions may also be influenced by the emotional context surrounding the unexpected nature of CPA, potentially affecting retrospective evaluations of symptoms and the perceived quality of death [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003eClinical Implications\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis study reinforces the importance of early structured ACP and family-centred communication, particularly for patients at risk of sudden deterioration at home. Policy efforts should also address the gaps in emergency preparedness and equitable access to EOL care, including enhanced support for home-based and community palliative services.\u003c/p\u003e\u003cp\u003eFuture studies should also focus on identifying optimal strategies to improve ACP and emergency planning for high-risk patients. Integrating qualitative insights may advance intervention development and clarify the decision-making dynamics around EMS and resuscitation.\u003c/p\u003e\u003cp\u003e\u003cem\u003eStrengths and Limitations\u003c/em\u003e\u003c/p\u003e\u003cp\u003ePrevious studies on EMS use and aggressive EOL care in patients with cancer have largely focused on ICU admission, late chemotherapy, and place of death [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Few studies have described the specific characteristics of patients having CPA during emergency transport or explored the relationship between communication practices and EOL experiences. This study provides new insights into disease-specific patterns, socioeconomic disparities, and EOL communication practices.\u003c/p\u003e\u003cp\u003eThis study had several limitations that should be considered when interpreting the findings. First, the data relied on retrospective reports from bereaved family members, which may have been subject to recall bias. Proxy accounts may not fully reflect the actual experiences or preferences of patients, especially concerning EOL care discussions. The time lag between the patient\u0026rsquo;s death and the survey (13\u0026ndash;25 months) may have contributed to this recall bias. Second, key variables such as CPA status at the time of emergency transport and the presence or absence of resuscitation were based on family-reported data and may not align precisely with clinical records or standardized definitions. In addition, the timing of DNR documentation and EOL care discussions in relation to the cardiac arrest event was not assessed, limiting interpretation of their sequence. Third, although the analytic outcome in this study was whether patients in CPA were transported by EMS near the EOL, the appropriateness or timing of EMS use and whether it reflected patient preferences or clinical needs could not be assessed. Finally, because this study employed a cross-sectional design, any observed differences should be interpreted descriptively rather than causally. Future research should benefit from prospective data collection, triangulation with medical records, and mixed-method approaches, including qualitative studies exploring the decision-making processes and communication dynamics surrounding emergency care and resuscitation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003ch2\u003eEthics approval\u003c/h2\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of the National Cancer Center of Japan (reference number 2017\u0026thinsp;\u0026minus;\u0026thinsp;346; approved on June 5, 2018) and conducted in accordance with the Ethical Guidelines for Medical and Biological Research Involving Human Subjects in Japan.\u003c/p\u003e\n\u003ch2\u003eConsent\u003c/h2\u003e\n\u003cp\u003eConsent for participation was obtained by completing and returning questionnaires.\u003c/p\u003e\n\u003ch2\u003eData, material, and/or code availability\u003c/h2\u003e\n\u003cp\u003eThe data of decedents are not publicly available due to restrictions on data sharing.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis study was supported by a Grant-in-Aid for Scientific Research from the Ministry of Health, Labor and Welfare, Japan (grant number 24EA1005).\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eYoko Nakazawa: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing\u0026mdash;original draft. Mitsunori Miyashita: Conceptualization, Methodology, Supervision, Writing\u0026mdash;review \u0026amp; editing. Tatsuya Morita: Conceptualization, Methodology, Supervision, Writing\u0026mdash;review \u0026amp; editing. Yasuyuki Okumura: Formal analysis, Methodology, Supervision, Writing\u0026mdash;review \u0026amp; editing. Yoshiyuki Kizawa: Conceptualization, Methodology, Supervision, Writing\u0026mdash;review \u0026amp; editing. Shohei Kawagoe: Supervision, Writing\u0026mdash;review \u0026amp; editing. Hiroshi Yamamoto: Supervision, Writing\u0026mdash;review \u0026amp; editing. Emi Takeuchi: Investigation, Writing\u0026mdash;review \u0026amp; editing. Risa Yamazaki: Investigation, Writing\u0026mdash;review \u0026amp; editing. Asao Ogawa: Conceptualization, Funding acquisition, Project administration, Writing\u0026mdash;review \u0026amp; editing.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eThe authors express their gratitude to the bereaved family members who participated in the study.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe data of decedents are not publicly available due to restrictions on data sharing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCrawford GB, Dzierżanowski T, Hauser K, et al. Care of the adult cancer patient at the end of life: ESMO Clinical Practice Guidelines. \u003cem\u003eESMO Open\u003c/em\u003e 2021; 6: 100225. 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DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1200/jco.19.00018\u003c/span\u003e\u003cspan address=\"10.1200/jco.19.00018\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Cardiopulmonary Arrest, Emergency Medical Services, Neoplasms, Terminal Care, Palliative Care, Advance Care Planning, Resuscitation, Bereavement","lastPublishedDoi":"10.21203/rs.3.rs-7250687/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7250687/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eEmergency medical service (EMS) transport during the terminal stage of cancer may result in cardiopulmonary arrest (CPA) and resuscitation, which may not align with patient preferences. The characteristics and care experiences of patients transported in CPA have not been well studied in Japan. This study aimed to describe the characteristics and end-of-life (EOL) care experiences of patients with terminal cancer with and without CPA at EMS transport.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe conducted a secondary analysis of a nationwide mortality follow-back survey (2019\u0026ndash;2020), using structured questionnaires completed by bereaved family members and linked to death certificates. We analyzed 4,939 patients with terminal cancer who were transported by EMS in the final month of life and died in hospitals between 2017 and 2018. Patients were categorized based on their CPA status at EMS transport.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAmong 4,939 patients, 178 (3.6%) had CPA. The CPA group had more lung cancer (+\u0026thinsp;8.0%) and less colorectal (\u0026minus;\u0026thinsp;7.2%) and hepatobiliary/pancreatic cancers (\u0026minus;\u0026thinsp;8.2%). They were less likely to have reported do-not-resuscitate status (55.9% vs. 92.6%), had in resuscitation discussions (46.5% vs. 62.1%), or EOL discussions with family (39.5% vs. 50.8%). Out-of-pocket expenses were lower (41.2% under \u0026yen;100,000 vs. 21.7%). They reported lower symptom burden and slightly higher perceived death quality (+\u0026thinsp;5.0 points).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003ePatients transported in CPA experienced fewer EOL discussions and preparedness, socioeconomic disparities, and distinct perceptions of death quality. These findings emphasize the need to enhance advance care planning communication and emergency preparedness in EOL cancer care.\u003c/p\u003e","manuscriptTitle":"End-of-life emergency medical service transport among patients with terminal cancer, by cardiopulmonary arrest status: A nationwide mortality follow-back survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-12 14:26:28","doi":"10.21203/rs.3.rs-7250687/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-05T20:24:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-27T14:56:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-19T01:08:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"130730001073844624357263616703509167699","date":"2025-10-04T15:59:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"13497641668290546083735403196376900847","date":"2025-09-29T16:26:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-29T14:55:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-02T21:39:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-31T22:57:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2025-07-30T08:39:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"e21034d8-588e-4683-b618-6014029a85dc","owner":[],"postedDate":"October 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T17:22:11+00:00","versionOfRecord":{"articleIdentity":"rs-7250687","link":"https://doi.org/10.1007/s00520-025-10309-y","journal":{"identity":"supportive-care-in-cancer","isVorOnly":false,"title":"Supportive Care in Cancer"},"publishedOn":"2026-01-13 16:29:13","publishedOnDateReadable":"January 13th, 2026"},"versionCreatedAt":"2025-10-12 14:26:28","video":"","vorDoi":"10.1007/s00520-025-10309-y","vorDoiUrl":"https://doi.org/10.1007/s00520-025-10309-y","workflowStages":[]},"version":"v1","identity":"rs-7250687","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7250687","identity":"rs-7250687","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}