Our study found that the higher mortality rates at ICU (66.9% vs 54.7%) and one-year after ICU (87.7% vs 79.1%) occurred in cancer group than non-cancer group. Differently, the review study  indicated that there were no different ICU mortality rates between cancer and non-cancer patients. The inconsistent results suggest that the poor mortality rates in ICU likely occurred in cancer patients at terminal stage. Our mortality rates were comparatively higher than ICU mortality rates of 17.2% and a one-year mortality rate of 23.8% reported by Lobo et al , analyzing 84 countries. The cohort study found that compared with non-cancer group, Chinese cancer patients with stage IV after receiving CPR showed the lower post-discharge survival rates and poorer prognosis . Cancer patients at stage IV predicting higher mortality rates in ICU was also observed in Western society . Therefore, this study and our study supports that for terminal cancer patients, palliative care not CPR or life-sustaining treatment is more appropriate for their end of life quality .
This study indicated that compared with non-cancer group (14%), there were lower withdrawal rates at ICU in cancer group (6.5%). Terminal cancer patients’ low withdrawal from life-sustaining treatments was significantly lower than the 13.9% , 17.8% , and 13.2%  reported in the recent studies on the ICU patients in western societies. Our study and the recent study indicated that the terminally ill patients often received high-intensity life-sustaining treatments . Compared with families in non-cancer group (39.5%), near half of families (49.4%) in cancer group refused to hospice care consultation in ICU. Similar to the previous studies on end of life decision in Chinese society [17,18, 19], this study also indicated that the patients' family members were the primary decision makers for the withdrawal of life-sustaining treatments and most Chinese families of terminal cancer patients rejected the withdrawal of life-sustaining treatments in order to prolong the patient’s life. The previous study also showed 79% Chinese families chose not to withdrawal life-sustaining treatments for their family members with critical illness . The cohort study in Taiwan  found that patient-caregiver agreement on life sustaining treatment-preference was poor-to-fair and families more preferred aggressive treatments than patients’ wish. The previous studies [17,18, 21] indicated that the value of filial piety based on Confucian teaching (a Chinese theory of virtue ethics and deontology) influences adult children’ caregiving behaviors which focus on task fulfillments and emphasizes the novel treatments to prolong life for their parents at the end of life stage. Confucian ethics of filial piety defines the duties and obligations between parents and children in order to remain hierarchy within the family system and family harmony . This value drives children’s motivations of caregiving for their elderly patients at the end of life to show their love, respect, and appreciation for the care they had received from their parents, and to avoid shame and guilt for not being a good child in Chinese cultural context [17,18, 21]. The results suggest that cultural value might influence Chinese families not to withdrawal of life-sustaining treatment which might show doing nothing for their love one as a result of their sense of guilt.
After adjusting for age and APACHE II scores, the multivariate Cox analysis indicated that mechanical ventilation, enteral and parenteral nutrition significantly increased the risk of ICU mortality rates among terminal cancer patients. The recent review study  also found that invasive mechanical ventilation predicted the higher hospital mortality in cancer patients. The study  demonstrated the positive correlation of mechanical ventilation with mortality rates might suggest that there were the negative impacts of mechanical ventilation on barotrauma, oxygen toxicity, hemodynamic compromise, ventilator-induced lung injury, ventilator-associated pneumonia, as well as local and systemic effects of tumor. Our study also showed that enteral nutrition increased both ICU and one-year mortality rates. The cohort study in Taiwan also found that while terminal cancer patients preferred to reject all life-sustaining treatments, their families wanted to continue with nutritional supports by intravenous or/and tube feeding . The review study revealed that providing nutrition and hydration was perceived by families as the humanistic end of life care for terminal cancer patients . Feeding might be considered by family members as the fundamental supportive care for the patients’ to be alive and also as the way of expressing filial piety in Chinese societies [9, 25]. Not providing nutrition support might be considered not behaving as a “filial piety” child. As a result, they might receive social blame. Moreover, without nutrition support, in Chinese culture, people dying in hungry status might lead them to become a ‘‘starving soul’’ or ‘‘hungry ghost/spirit’’ . Accordingly, Chinese families are reluctant to withdrawal nutrition support for terminal cancer patients. However, our study revealed that the negative impacts of nutrition support on poor survival rates for terminal cancer patients.
This study found that there was no DNR designation prior to ICU admission for two groups. Moreover, higher utilizations of hospital care from general wards were found in cancer group than non-cancer group. The results suggest that terminal cancer patients and their families could have the opportunities to discuss and achieve the agreements about end of life decision including DNR and withdrawal of life-sustaining treatments in general wards. Discussing about life-withdrawal treatments between Chinese cancer patients and their families is likely a cultural taboo . As a result, the patient-caregiver agreement on withdrawal life-sustaining treatment is unlikely achieved. Therefore, future intervention needs to be developed for terminal cancer patients and their families to facilitate their discussions not only DNR but also the preference to withdrawal life-sustaining treatments in general wards.
The study in Singapore also found that Chinese family was reluctant to accept their parent’s cancer diagnosis at terminally stage and they chose for life-prolonging treatments over palliative care . In Ho’s case study showed that after understanding the impact of cultural value on the Chinese family making decision at the end of life with honor the family’s wishes, this culturally sensitive communication can achieve a consensus and help the patient die peacefully. The study in the west  also emphasized that respecting the families’ culture and belief and allowing their cultural practices and rituals such as care provided by traditional healers are considered as the form of supports for families with different ethnic groups. Moreover, helping families to be present with participating in direct care at the patient’s bedside is also regarded as an effective form of support for families and communication between the family and the patient.
The main limitation of this study is related to the retrospective design with chart review method which depends on the availability and accuracy of the medical record. Future research with a prospective study design can also include the self-report of the patients and their families in data collection to explore their experiences of end of life decision and care.