DNR Orders, Death Pronouncement and Notification

1. DNR Orders, Death Pronouncement and Notification Matthew S. Ellman, MD ICM, March, 2010

2. Content • How to talk with patients about DNR orders • How to do death pronouncement • Death notification

3. Advance Directives • Laws and forms vary • 2 types: • Health care power of attorney • Living will • Misconceptions • Advanced Directive means “don’t treat” • Named proxy means pt loses control • Only old people need advance directives.

4. Advance Directives/DNR discussions: Hospital Admissions • Start with goals of care and clinical scenario. • “Perfunctory” vs. life-threatening condition

5. “Perfunctory” • Normalize • “Hospital policy tells us that we should talk with all patients admitted about their wishes regarding health treatment preferences, including advance directives and cardiopulmonary resuscitation” • Opportunity to • elicit patient concerns/fears • clarify misconceptions about condition, prognosis, and treatment options.

6. DNR orders in the Hospital • Establish goals of care • Do your homework!

7. CPR Outcomes • Survival 20 minutes after CPR • 44% • Survival to discharge • 17% • VT/VF survival to d/c: 35% • Pulseless or asystole survival to d/c:10% • Pre-CPR 84% came from home; among survivors • 51% returned home

8. “Talking points” for patients • 17% or 1 in 6 who undergo CPR in the hospital may survive to discharge • Specific co-morbidities reduce survival • Surviving patients at risk for CPR related complications

9. DNR Discussion: 6 steps • Establish setting • What does patient understand? • What does patient expect/goals of care? • Discuss DNR order • Respond to emotion • Establish a plan

10. Establish setting • Ensure comfort, privacy • Ask who should be present • Open generally: “I’d like to speak with you about possible health care decisions in the future”

11. What does patient understand? • Understanding illness / prognosis for necessary for informed decision • “What do you understand about your health situation?” • Get the patient talking • If understanding inaccurate-- now is time to review/correct

12. What does the patient expect? • Ask/listen: • “What do you expect in the future?”, • “What goals do you have for the time you have left?” • If unrealistic, clarify • Ask pt. to explain values underlying preferences. • Clarify/confirm • E.g.: “So what you’ve said is that you want us to do everything we can to fight but when the time comes, you want to die peacefully”

13. Unreasonable requests for CPR • Inaccurate information about CPR • General public: CPR works 60-85% • Patient and family hopes, fears and guilt • Distrust of medical care system

14. Prognosis (median survival): Common cancer syndromes • Malignant hypercalcemia: 8 weeks (except newly diagnosed myeloma or breast) • Malignant pericardial effusion: 8 weeks • Carcinomatous meningitis: 8-12 weeks • Multiple brain mets.: 3-6 mos. with RT, 1-2 mos without. • Malignant ascites, pleural effusion, bowel obstruction: < 6months.

15. Discuss DNR order • Use language patient understands • Don’t introduce CPR in mechanistic terms: “…intubation, CPR, press on your chest, tube down your throat, mechanical ventilation” • Consider using word “die” or “if heart stops/unable to breath on your own”: clarifies that CPR is treatment tries to reverse death. • Never say: “Do you want us to do everything?”

16. Discuss DNR order • If appropriate, make clear recommendation against CPR. • “We have agreed that the goals of care are to keep you comfortable…with this in mind I do not recommend the use of artificial or heroic means to keep you alive. If you agree, I will write an order in your chart that if you die, no attempt to resuscitate you will be made.”

17. DNR discussion • If prognosis unclear and/or goals uncertain, ask about CPR • “If you should die (or if your heart stops or you are unable to breath on your own) in spite of all our efforts, do you want us to use heroic measures to attempt to bring you back?” • If asked to explain: Describe purpose, risks and benefits of CPR.

18. Respond to Emotion • Strong emotions responses common, brief • N.U.R.S. • Silence may be best, reassuring touch, tissues.

19. Establish a plan • Clarify orders for overall goals, not just DNR status • Do not use DNR as proxy for other treatments • “We will continue maximal medical therapy to meet you goals, however if you die, we won’t use CPR to bring you back” • Or: “It sounds like we should move to a plan to maximize your comfort, so in addition to DNR order, I will ask our palliative care team to see you.”

20. Video • Look for 6 steps • What did MD do that did/did not work well? • Think about what have you seen on the wards

21. Death Pronouncement • More than actual declaration of death • 3 key steps • Examining patient to determine death • Record proper documentation • Notifying families Ref: www.mcw.edu/EPERC/FastFactsandConcepts, Heidenriech and Weissman, MD, 2000

22. “Please come to pronounce this patient” • Preparation • In the room • Pronouncement • Documentation medical record • Notification – attending, relatives

23. Coroner’s/M.E. Reportable Case • If patient in hospital <24 hours • If death unexpected, unusual circumstances • If death assoc w/trauma or a procedure • Death during surgery or anesthesia • Other - varies by state law

24. Pronouncement Video Clips • Observe • MD behavior • Daughter’s reactions • What you have seen in the hospital?

25. Informing Significant Others • Family and friends look to MD for information, reassurance and direction • Lasting impressions and memories • Affects grief process, integration of loss

26. Overview of Notification • Preparation • Meeting with family/significant others • Follow-up

27. Notification: preparation • Confer with nursing, other staff • Review record • Examine patient • Find private place to meet • Involve other members of team • Learn names of those you will talking to and relationship to deceased

28. Notification: Meeting with significant others • Introduce yourself, identify others • Invite to sit down with you • Use eye contact & touch if appropriate • Express condolence: “I’m sorry for your loss” • Talk openly about death – use “died’ or “dead” initially, then use words family uses • Identify, respect culture & religion

29. Meeting with significant others • If requested, explain cause of death in non-medical terms • Offer assurance everything done to keep person comfortable • Be prepared: range of emotion • Offer opportunity to see deceased • Prepare family

30. Seeing the deceased with significant others • Model touching & talking to deceased • Offer time alone, assure no rush • Provide time to process before discussing autopsy/ organ donation • Offer to return should questions arise • Provide info for family to reach you

31. Follow-up • Personalize sympathy card • Consider attending wake, funeral • Consider referral to bereavement support • Encourage bereaved to see MD in 4-6 mos. • Invite bereaved to meet with you re: questions/concerns; autopsy results

32. Organ donation request • Determine eligibility ahead of time • OPO & med. team should approach family together • When? - after family realizes loved one will die • OD cards are legally binding – tell don’t ask family • Communication correlates of donation: • Discussing specifics, incl. issues of cost, effects on funeral • Family spending time with OPO staff • Psychosocial support for grieving family

33. Autopsies: how families may benefit • Discover inherited/familial/(infectious) conditions • Uncover work-related disease • Provide info. to settle insurance/death benefits • Ease stress of unknown; finding dx/tx appropriate may provide comfort • Medical knowledge gained may help others which may help ease pain of loss

34. Autopsies: common concerns • Body treated w/respect & dignity; family wishes maintained all times • Cost – usually none in teaching hospitals • Should not delay funeral or affect viewing • Some organs may be kept for detailed exam • Most major religions leave decision to next- of-kin

35. Telephone Notification • Can be challenging & stressful • Dilemma: on the phone or ask to come in? Factors to consider: • Death expected or not • Relationship to and how well you know family • Anticipated emotional reaction • Whether person will be alone, level understanding • Distance, transportation, time of day

36. Telephone Notification • Prepare for the call • Find quiet place to phone • Call as soon as possible • When delay likely, responsibility should be taken by covering MD

37. Telephone Notification • Identify yourself • Identity of person reach • Ask to speak with person closest, ideally: proxy or contact person • Avoid responding until you have verification of identity • No notification to minors

38. Telephone Notification: What to say • Buckman: “giving bad news” • Prepare • What does patient know • (What does patient want to know) • Share the news (“warning shot”) • Respond to emotion • Plan

39. Phone notification: what to say • If no prior relationship, ask what they know of condition: “What have MDs told you…?” • Warning shot • Clear direct language: “I’m sorry, ----- has just died.” (not “expired”, “passed away”, “didn’t make it”) • Speak clearly & slowly • Allow time for questions • Be empathic

40. Phone notification: considerations • Arrange to meet family • Ask if you can contact anyone for them • Do not leave news on voice mail • If no contact in 1-2 hours – use social work • If you feel uncomfortable, ask for help

41. Conclusions • Observe role models, mentors • Prepare • Keep the dialogue patient-centered • Respond to emotion • Remember: patients will not forget