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![DNR VS DNAR
• DNR IS MISLEADING AS IT IMPLIES THAT CPR IS ALWAYS POSSIBLE &
SUCCESSFUL. SO, IF YOU CHOOSE DNR, YOU CHOOSE TO FORGO A
SUCCESSFUL INTERVENTION.
• DNAR [DO NOT ATTEMPT RESUSCITATION] IS MORE ACCURATE AS IT
INDICATES THAT NO EFFORT WILL BE MADE TO ATTEMPT AN INTERVENTION
THAT HAS A LOW RATE OF SUCCESS FOR PATIENTS REACHING THE END OF
THEIR LIVES.](https://image.slidesharecdn.com/noonconfcodestatus-180710165731/75/Noon-conf-code-status-21-2048.jpg)
![CURRENT STATE:
• DNAR DISCUSSIONS HAPPEN TOO LITTLE & TOO LATE.
• MAJORITY OF DNAR ORDERS WRITTEN WITHIN 2-3 DAYS BEFORE DEATH.
• 500 PTS WHO SUFFERED CARDIAC ARREST, 76% OF THESE PTS WITH DNAR
ORDERS WERE INCAPACITATED AT THE TIME DNAR ORDER DISCUSSED. [ONLY
11% WERE IMPAIRED AT ADMISSION]. [BEDELL ET AL, JAMA 1986]
• DNAR DISCUSSIONS FAIL TO SATISFY INFORMED CONSENT.
• RARELY DO WE DISCUSS THE PATIENT’S GOALS, EXPLAIN THE CHANCES FOR
SURVIVAL, THE ASSOCIATED HARMS, AND THE ALTERNATIVES.
• HEALTH CARE PROFESSIONALS INAPPROPRIATELY EXTRAPOLATE
DNAR ORDERS TO OTHER DECISIONS.
• SURVEY OF 155 RESIDENTS: 43% WOULD WITHHOLD BLOOD PRODUCTS & 32%
WOULD NOT GIVE ANTIBIOTICS AFTER MAKING SOMEONE DNAR. [ARCH INTERN MED.
1988]](https://image.slidesharecdn.com/noonconfcodestatus-180710165731/75/Noon-conf-code-status-22-2048.jpg)
![SURVIVAL STATISTICS [IN-HOSPITAL ARREST]
Variable % survival at discharge
Overall average 17.5%
Age >75 1.3%
Age > 90 0.1% [n=576 pts]
Any Malignancy 6.6%
Stage IV malignancy 1.9%
Impaired renal function [any] 8%
Diabetes 11.7%
COPD 12%
One active diagnosis 21%
Primary diagnosis of CV disease 23%
Prior good health 27%
Arrhythmia 50%
CPR success rate on TV 64% [NEJM 1996]
From:
Ebell and Afonso.
Pre-arrest
predictors of
failure to survive
after in-hospital
CPR: a meta-
analysis. Family
Practice (2011)
28 (5): 505-515.
Meta-analysis of
35 studies with
96,499 pts.](https://image.slidesharecdn.com/noonconfcodestatus-180710165731/75/Noon-conf-code-status-25-2048.jpg)
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Noon conf code status
- 1. CODE STATUS DISCUSSIONS: CRUSHING EXPECTATIONS .. . MARK BEITER, DO FACP PALLIATIVE CARE NOON CONFERENCE JULY 10, 2018
- 4. OBJECTIVES • BRIEF INTROTO PALLIATIVE CARE AT VM • IMPROVE YOUR COMFORT LEVEL AROUND DISCUSSING CODE STATUS BY: • BREAKING DOWN MISCONCEPTIONS ABOUT CPR. • REVIEWING SURVIVAL DATA WITH CPR. • PROVIDING TOOLS TO ENHANCE INFORMED DISCUSSIONS WITH YOUR PATIENTS.
- 5. DEFINITION OF PALLIATIVECARE • PALLIATIVE CARE IS SPECIALIZED MEDICAL CARE FOR PEOPLE LIVING WITH SERIOUS ILLNESS. • IT FOCUSES ON PROVIDING RELIEF FROM THE SYMPTOMS AND STRESS OF A SERIOUS ILLNESS. • THE GOAL IS TO IMPROVE QUALITY OF LIFE FOR BOTH THE PATIENT AND THE FAMILY. • PALLIATIVE CARE IS PROVIDED BY A TEAM OF PALLIATIVE CARE DOCTORS, NURSES, SOCIAL WORKERS, CHAPLAINS AND OTHERS WHO WORK TOGETHER WITH A PATIENT’S OTHER DOCTORS TO PROVIDE AN EXTRA LAYER OF SUPPORT. • IT IS APPROPRIATE AT ANY AGE AND AT ANY STAGE IN A SERIOUS ILLNESS AND CAN BE PROVIDED ALONG WITH CURATIVE TREATMENT. Center to Advance Palliative Care
- 6. COMMON MISCONCEPTIONS .. . • “I AM NOT READY FOR PALLIATIVE CARE.” • PALLIATIVE CARE IS NOT: • ONLY END OF LIFE CARE • JUST FOR CANCER PATIENTS • FOR THOSE WHO HAVE STOPPED CURATIVE TREATMENT • THE SAME AS HOSPICE
- 7. EVIDENCE TO SUPPORTPALLIATIVE CARE • MULTIPLE STUDIES HAVE SHOWN THAT PALLIATIVE CARE SERVICES: • IMPROVE PATIENTS’ SYMPTOMS AND QUALITY OF LIFE, • AVOID HOSPITALIZATION, • LEAD TO BETTER PATIENT & FAMILY SATISFACTION, • CAN HAVE A POSITIVE IMPACT ON SURVIVAL, • REDUCE CAREGIVER BURNOUT, • DECREASE COSTS.
- 9. WHAT WE DO: •LISTEN TO THE PATIENT STORY. • FIND OUT THEIR UNDERSTANDING OF THEIR ILLNESS AND THEIR EXPECTATIONS FOR THEIR TREATMENT. • DISCOVER WHAT GIVES THEM HOPE, MEANING AND PURPOSE. • ALIGN THE CURRENT TREATMENT PLAN WITH THEIR EXPECTATIONS. • HELP PROGNOSTICATE AND PROVIDE A REALISTIC UNDERSTANDING OF THEIR FUTURE AND THEIR CHOICES. • PROVIDE SUPPORT, EMOTIONALLY AND SPIRITUALLY, TO THE PATIENT AND THEIR FAMILIES. • TREAT SUFFERING, IE PAIN AND DYSPNEA MANAGEMENT. • EXPLORE AND RESOLVE EMOTIONAL AND PHYSICAL DISTRESS/CONFLICT. • PROVIDE CONTINUITY IN A SEA OF CHANGE.
- 10. Quality of Life= Reality - Expectations Diagnosis Size of the Gap inversely related to QoL.
- 11. VM CURRENT STATE •TEAM: 2 PHYSICIANS,2 LICSW, 1 RN & 1CHAPLAIN • M-F • OUTPATIENT PRESENCE IN ONCOLOGY CLINIC 2 DAY/WK • NEW MD & APP TO START IN THE FAL • HOW TO CONSULT US: • VNET ON CALL SCHEDULE, M-F 9-5 • INITIAL CONSULT NOTE IN ADVANCED DIRECTIVE NOTES (FOLLOW UPS UNDER INPT PROGRESS NOTES)
- 12. VM PALLIATIVE CARETEAM Mark Beiter, DO Kari Hilwig, MSW Liz Powell, LICSW Cindy Kirtland, Spiritual Care Ted Dropcho, MD Edit Shalom, RN Jeanette Liao, MD Starting in late Sept.
- 13.
- 14. “HOPE IS DEFINITELYNOT THE SAME THING AS OPTIMISM. IT IS NOT THE CONVICTION THAT SOMETHING WILL TURN OUT WELL, BUT THE CERTAINTY THAT SOMETHING MAKES SENSE, NO MATTER HOW IT TURNS OUT.” • … VACLAV HAVEL DISTURBING THE PEACE
- 16. WHAT IS THEAVERAGE SURVIVAL TO DISCHARGE RATE FOR IN-HOSPITAL CPR? • A. 5% • B. 15% • C. 25% • D. 45% • E. 55%
- 17. WHAT IS THEAVERAGE SURVIVAL TO DISCHARGE RATE FOR IN-HOSPITAL CPR? • A. 5% • B. 15% • C. 25% • D. 45% • E. 55%
- 19. WHAT DOES THEAVERAGE PATIENT OVER 70 YO BELIEVE TO BE THE SURVIVAL RATE FOR IN-HOSPITAL CPR? • A. 15% • B. 30% • C. 50% • D. 65% • E. 75%
- 20. WHAT DOES THEAVERAGE PATIENT OVER 70 YO BELIEVE TO BE THE SURVIVAL RATE FOR IN-HOSPITAL CPR? • A. 15% • B. 30% • C. 50% • D. 65% • E. 75% Survey of 100 pts > 70 years old: • 81% believed the success rate was >50% • 23% believed it to be 90% or better
- 21. DNR VS DNAR •DNR IS MISLEADING AS IT IMPLIES THAT CPR IS ALWAYS POSSIBLE & SUCCESSFUL. SO, IF YOU CHOOSE DNR, YOU CHOOSE TO FORGO A SUCCESSFUL INTERVENTION. • DNAR [DO NOT ATTEMPT RESUSCITATION] IS MORE ACCURATE AS IT INDICATES THAT NO EFFORT WILL BE MADE TO ATTEMPT AN INTERVENTION THAT HAS A LOW RATE OF SUCCESS FOR PATIENTS REACHING THE END OF THEIR LIVES.
- 22. CURRENT STATE: • DNARDISCUSSIONS HAPPEN TOO LITTLE & TOO LATE. • MAJORITY OF DNAR ORDERS WRITTEN WITHIN 2-3 DAYS BEFORE DEATH. • 500 PTS WHO SUFFERED CARDIAC ARREST, 76% OF THESE PTS WITH DNAR ORDERS WERE INCAPACITATED AT THE TIME DNAR ORDER DISCUSSED. [ONLY 11% WERE IMPAIRED AT ADMISSION]. [BEDELL ET AL, JAMA 1986] • DNAR DISCUSSIONS FAIL TO SATISFY INFORMED CONSENT. • RARELY DO WE DISCUSS THE PATIENT’S GOALS, EXPLAIN THE CHANCES FOR SURVIVAL, THE ASSOCIATED HARMS, AND THE ALTERNATIVES. • HEALTH CARE PROFESSIONALS INAPPROPRIATELY EXTRAPOLATE DNAR ORDERS TO OTHER DECISIONS. • SURVEY OF 155 RESIDENTS: 43% WOULD WITHHOLD BLOOD PRODUCTS & 32% WOULD NOT GIVE ANTIBIOTICS AFTER MAKING SOMEONE DNAR. [ARCH INTERN MED. 1988]
- 23. Misconceptions About DNAROrders • CPR is a benign procedure with no potential risks. It always restores life & restores it to its previous level. • DNAR means death is imminent.
- 24.
- 25. SURVIVAL STATISTICS [IN-HOSPITALARREST] Variable % survival at discharge Overall average 17.5% Age >75 1.3% Age > 90 0.1% [n=576 pts] Any Malignancy 6.6% Stage IV malignancy 1.9% Impaired renal function [any] 8% Diabetes 11.7% COPD 12% One active diagnosis 21% Primary diagnosis of CV disease 23% Prior good health 27% Arrhythmia 50% CPR success rate on TV 64% [NEJM 1996] From: Ebell and Afonso. Pre-arrest predictors of failure to survive after in-hospital CPR: a meta- analysis. Family Practice (2011) 28 (5): 505-515. Meta-analysis of 35 studies with 96,499 pts.
- 26.
- 27.
- 29. THE CEREBRAL PERFORMANCECATEGORY (CPC) SCORE • CPC SCORE OF 1 = GOOD CEREBRAL PERFORMANCE. • CONSCIOUS, ALERT, AND ABLE TO WORK BUT MIGHT HAVE MILD NEUROLOGIC OR PSYCHOLOGICAL DEFICITS (SUCH AS MILD DYSPHAGIA OR MINOR CRANIAL NERVE ABNORMALITIES). • CPC SCORE OF 2 = MODERATE CEREBRAL DISABILITY. • ABLE TO LIVE INDEPENDENTLY AND WORK IN A SHELTERED ENVIRONMENT. DISABILITIES MAY INCLUDE HEMIPLEGIA, SEIZURES, ATAXIA, DYSPHAGIA, OR PERMANENT MEMORY OR MENTAL CHANGES. • CPC SCORES OF 3 THROUGH 5 PROGRESS THROUGH SEVERE CEREBRAL DISABILITY, COMA OR VEGETATIVE STATE, AND FINALLY BRAIN DEATH.
- 30.
- 31. APPROACHES TO CODESTATUS DISCUSSIONS:
- 37. TALKING ABOUT CODESTATUS www.vitaltalk.org
- 38. USE GUIDE FORDISCUSSING SERIOUS NEWS • 1. GET READY • 2. UNDERSTAND • 3. INFORM • 4. DIGNIFY EMOTION • 5. EQUIP THE PATIENT FOR THE NEXT STEP
- 39. NURSE HOW TORESPOND TO EMOTION NAME “ It sounds like you are frustrated.” In general, turn down the intensity a notch when you name the emotion. UNDERSTAND “This helps me understand what you are thinking.” Think of this as another kind of acknowledgment. Stop short of suggesting that you understand everything (you don’t). RESPECT “I can see that you’ve really been trying to follow our instructions.” Praise also fits in here: e.g. “I think you have done a great job with this.” SUPPORT “I will do my best to make sure you have what you need.” Making this kind of commitment is a powerful statement. EXPLORE “Could you say more about what you mean when you say that…” Asking a focused question prevents this from seeming too obvious.
- 40. INFORMED CONSENT • ELICITPATIENT’S TREATMENT GOALS AND VALUES. • EDUCATE THE PATIENT ABOUT THEIR DISEASE COURSE, PROGNOSIS, POTENTIAL BENEFITS AND BURDENS OF CPR & THE ALTERNATIVES TO CPR, IE FRAME THE DISCUSSION. • DISCUSS SUCCESS RATES - THIS IS CRITICAL AS MOST PATIENTS HAVE UNREALISTICALLY HIGH EXPECTATIONS ABOUT CPR. • CONSIDER PROVIDING A RECOMMENDATION BASED ON YOUR DISCUSSION.
- 41. DISCUSSING DNAR ORDERS •ALLOW TIME, PRIVACY & SIT DOWN! • WHAT DOES THE PATIENT UNDERSTAND ABOUT THEIR PROGNOSIS? ASK OPEN ENDED QUESTIONS. • WHAT DOES THE PATIENT EXPECT? • WHAT DO YOU THINK WOULD BE DONE DIFFERENTLY, AFTER THE RESUSCITATION, THAT WASN'T BEING DONE BEFORE? • DISCUSS WHAT CPR IS AND WHAT A DNAR ORDER MEANS? IN LANGUAGE THE PATIENT WILL UNDERSTAND. • RESPOND TO EMOTIONS* • ESTABLISH A PLAN. • MAKE SURE THE PATIENT DOES NOT FEEL ABANDONED AND THAT THEIR VOICE HAS BEEN HEARD.
- 42. A FEW OTHERTHINGS TO KEEP IN MIND . . .
- 43. IDENTIFY AND INCLUDETHE KEY DECISION MAKER.
- 44.
- 45.
- 46. USE GUIDE FORDISCUSSING SERIOUS NEWS • 1. GET READY • 2. UNDERSTAND • 3. INFORM • 4. DIGNIFY EMOTION • 5. EQUIP THE PATIENT FOR THE NEXT STEP
- 47. NURSE HOW TORESPOND TO EMOTION NAME “ It sounds like you are frustrated.” In general, turn down the intensity a notch when you name the emotion. UNDERSTAND “This helps me understand what you are thinking.” Think of this as another kind of acknowledgment. Stop short of suggesting that you understand everything (you don’t). RESPECT “I can see that you’ve really been trying to follow our instructions.” Praise also fits in here: e.g. “I think you have done a great job with this.” SUPPORT “I will do my best to make sure you have what you need.” Making this kind of commitment is a powerful statement. EXPLORE “Could you say more about what you mean when you say that…” Asking a focused question prevents this from seeming too obvious.
- 48. TAKE HOME POINTS •ACTUAL SURVIVAL TO HOSPITAL DISCHARGE AFTER CPR IS ~ 10-20% FOR ALL PATIENTS, AND < 5% FOR THE ELDERLY AND THOSE WITH SERIOUS ILLNESSES. • DNAR DOES NOT EQUAL COMFORT CARE! DNAR APPLIES TO WHEN A PATIENT DIES, IT DOES NOT MEAN LESS CARE PRIOR TO DEATH. • CONSIDER USING GUIDE & NURSE TO HELP NAVIGATE CODE STATUS DISCUSSIONS. • MAKE A RECOMMENDATION.
- 49. RESOURCES • HTTP://MISSINGLINK.UCSF.EDU/LM/CODESTATDISCUSS/ • HTTPS://WWW.GOFARCALC.COM/ •HTTP://WWW.VITALTALK.COM • EBELL AND AFONSO. PRE-ARREST PREDICTORS OF FAILURE TO SURVIVE AFTER IN- HOSPITAL CPR: A META-ANALYSIS. FAMILY PRACTICE 2011;28 (5): 505-515.
- 50.
Editor's Notes
- #2 As a palliative care doctor – I talk about Code status with my patients on a daily basis. But these are often not easy discussions, and we rarely received formal education around how to have these discussions. And unfortunately, the data tells us that we are too often avoiding these conversations with our patients – but hopefully that is changing. But if you don’t feel confident having these discussions with your patients, don’t worry – you are not alone. My objective by the end of this talk is to make you more inspired and prepared to have these conversations with your patients in the future.
- #5 With CMS now allowing us to bill for advanced care planning.
- #7 PC is At any point in illness Any patient Irrespective of goals of care A complement to hospice Optimal symptom management
- #11 British physician in the 1980s.
- #18 10.4% with a good neurologic outcome
- #20 How misconceptions among elderly patients regarding survival outcomes of inpatient cardiopulmonary resuscitation affect do-not-resuscitate orders JAOA 2006, asked 100 pts > 70 yo this ?: 81% believed their success rate was >50% & 23% believed it to be 90% or better.
- #21 How misconceptions among elderly patients regarding survival outcomes of inpatient cardiopulmonary resuscitation affect do-not-resuscitate orders JAOA 2006, asked 100 pts > 70 yo this ?: 81% believed their success rate was >50% & 23% believed it to be 90% or better.
- #22 First off – terminology. Effective Communication = word choice. In the palliative care literature . . . Recurrent theme today: helping the patient not feel like selecting a DNAR is = to giving up!!
- #23 CPR was developed in 1960 for selective use on acutely ill patients or victims of acute insult (drowning, electrical shock). Hospitals require CPR for all patients regardless of underlying illness, unless DNAR in chart. CPR talks: unrealistic expectations, place of fear/guilt/giving up, unprepared Re: mortality
- #24 Giving up. Patient feels that way & maybe we don’t want to see them give up!!!!! Death is not a failure.
- #26 Imperative to help pt have informed consent.: statistics, risks & alternatives. Remember statistics are numbers sometimes saying 1%, people hear – this is better than 0%. One study of 371 pts >60, 41% wanted CPR & after learning about the survival data, only 22% wanted CPR. Hospitals require CPR for all patients regardless of underlying illness, unless DNAR in chart. Study from NEJM in 2009 quoted 22.3% survival & AHA 2013 shows 23.9% from Get with the Guidelines – Resuscitation numbers but survival bias
- #28 >50000 pt. cohort study to come up with very low, low, average or higher than average likelihood of success
- #41 Need to have meaningful discussion with your patient. The use of CPR may prolong death and suffering without adding to quality of life.
- #42 2 main points: If it is not going well, call out the emotion & don’t train roll your agenda – Leave your agenda at the door. Don’t have to do all in one sitting.