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The ABC’s of DNR

The ABC’s of DNR. Gary Winzelberg, MD MPH Division of Geriatric Medicine Palliative Care Program 01/05/10. Questions. Challenging DNR discussions Easy discussions Observations of attendings, fellows Attending feedback. Internship Memory/Flashback.

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The ABC’s of DNR

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  1. The ABC’s of DNR Gary Winzelberg, MD MPH Division of Geriatric Medicine Palliative Care Program 01/05/10

  2. Questions • Challenging DNR discussions • Easy discussions • Observations of attendings, fellows • Attending feedback

  3. Internship Memory/Flashback • Chronically ill (elderly) patient admitted with… • “Is Mr. Smith DNR?” • “I don’t know.” • “He should be.” • Pressure to get DNR order • Discomfort when caring for “full code” chronically ill patients – What are we doing? • DNR as symbol beyond actual order

  4. Objectives • Historical context • Data • CPR outcomes • Patient preferences • Communication strategies • Approach to advance care planning on admission

  5. DNR Order Pendulum at UNC • 2002 – DNR order required attending approval • Overnight calls to verbally approve DNR orders • 2009 – DNR orders written without any attending supervision • Consider code status discussions as a procedure

  6. Cardiopulmonary Resuscitation • Medical response to cardiac arrest • Defibrillation • Chest compressions • Medications • Intubation

  7. “Closed-Chest Cardiac Massage” • JAMA article, 1960 • Cardiac resuscitation limited by need for open thoracotomy and direct cardiac massage • Method of external transthoracic cardiac massage • 70% permanent survival rate, 20 patients • “Anyone, anywhere, can now initiate cardiac resucitative procedures. All that is needed are two hands.”

  8. CPR As Default Policy • 1965 reclassification as universal emergency procedure that anyone could perform • Initiate CPR regardless of medical condition • Principle that doctors should try to prevent death

  9. “Orders Not To Resuscitate” • 1976 NEJM article • Concern: inappropriate to apply technology to the fullest extent in all cases and without limitation • Increased awareness of patient rights

  10. CPR vs. DNR: Hospital Culture Tension • “Code status” dominant preoccupation of doctors & nurses when death seems near • Doctors often don’t want to talk about code status to sick patients or their families (& frequently don’t) • Patients & families don’t realize that they must request DNR • Doctors feel pressure to inform patients, families of their choice; families feel coerced, guilty, life or death responsibility Sharon Kaufman, …And A Time To Die

  11. “Should We Restart Your Heart?” • ER, Chicago Hope, Rescue 911 episodes (’94, ’95) • Majority of cardiac arrests caused by trauma • 28% arrests due to cardiac causes • 10% elderly • 77% short-term survival • 37% survival to discharge after CPR • CPR misrepresentations may lead patients to generalize impressions to CPR in real life Diem SJ, NEJM 1996

  12. Event: trauma Age: younger adults Rhythm: VF/VT Short-term survival: 75% Long-term survival: presumed good Function: normal Event: chronic illness Age: older adults (avg 70 yo) Rhythm: ½ VF, ½ asystole Hospital d/c survival: 18% Long-term survival: poor Function: impaired TV vs. Reality

  13. Out-of-Hospital CPR Outcomes(King County, WA) AgeSurvival to Hospital Discharge < 80 year old 19.4% 81-90 9.4% > 90 4.4% VF & VT < 80 year old 36% 81-90 24% > 90 17% Kim C, Arch Intern Med 2000

  14. Effect of Age on Surviving CPR • Weak association with decreased survival to hospital discharge • OR 0.92 (0.85-0.99) for every decade • Fewer octogenarians have VF/VT Kim C, Arch Intern Med 2000

  15. In-Hospital CPR Outcomes (Ehlenbach WJ, NEJM 2009) • 1992-05, >65 yo, 433,985 attempts • 18.3% survived to hospital discharge • No increase in survival during study period • Survival lower among: men 17.5% vs women 19.2%, older age (65-69 = 22% vs > 90 = 12%, coexisting illness (Deyo score >3 = 16% vs 19% if zero), admitted from SNF 11.5% vs 18.5% • Survival higher in MI (20.4% vs 17.8%) & CHF (20.4% vs 17.1%)

  16. In-Hospital CPR Outcomes (2) • A-A with lower survival (14.3) compared with whites (19.2%) • A-A more likely to receive care in hospitals with lower survival rates • Proportion of patients discharged home decreased over time (60% to 35%) • Proportion of patients discharged to SNF increased over time (15% to > 20%) • No data on functional outcomes

  17. CPR Preference & Survival Probability • 371 patients, mean age 77, 84% white Survival Rate (%) Opting for CPR (%) 1 10 5-10 10 20-40 22 50 25 > 60 8 Didn’t want CPR 25 Murphy DJ, NEJM 1994

  18. Survival Probability on Patient Preferences Chronic Illness Patients’ estimate = 15% + 16 CPR preference before learning probability = 11% CPR preference after learning probability = 5% Murphy DJ, NEJM 1994

  19. Functional Outcome After Hospital CPR • 162 survivors of in-hospital CPR • 56%: same or improved function • 44%: worse function at 2 months • Mean ADL decline: 3.9 (0-7 dependencies) • Eating, continence, toileting, transferring, bathing, dressing, walking • Age > 75 vs. < 55: OR 5.25 worse functional status Fitzgerald JD, Arch Intern Med 1997

  20. Factors associated with DNR Orders • Patient preference • 52% with DNR preference had written order • Probability of surviving for 2 months • Age • Orders written more quickly for patients > 75 independent of prognosis Hakim RB, Ann Intern Med 1996

  21. Code-Status Discussion Barriers • Qualitative study of family physicians & residents • Personal discomfort with confronting mortality • Fear of damaging the doctor-patient relationship • Fear of harming patient by discussing death • Limited time to establish trust • Difficulty in managing complex family dynamics Calam B, CMAJ 2000

  22. How Do Residents Discuss CPR? • 1992 UCSF study, audiotaped inpatient discussions • Median discussion length 10 minutes (2.5 – 36 mins) • Physician spoke 73% of time • Median time patients spoke: 2 min 30 sec • 13%: likelihood of CPR survival • 10%: discussion of patient goals, values Tulsky JA, J Gen Intern Med 1995

  23. Resident Approaches to Advance Care Planning on Admission Smith AK. Arch Intern Med 2006 • 2005 survey of Duke, Brigham medicine residents • 70% established CPR preference • 34% health care proxy, 36% advance directive • 32% discussed end of life care goals & values • 89% observed model of advance care planning • 37% received feedback • 47% -- goals/values important to discuss on admission • Barriers: time, know patient better, documentation pressures

  24. Overall Communication Approach • Establish preferred decision-makers, directives • Identify patients with clear CPR attempt preferences • Place code status in context • Treatment decisions • Patients’ goals, values • Patients’ medical condition • Support patients, families with end-of-life decision-making • Make recommendations • Give permission to choose approach other than disease-oriented focus

  25. Patients With DNR Directive • Attempt to confirm preference • Immunity from liability for complying with a directive • Opportunity to discuss care goals, treatment preferences • Care goals: longevity, function, comfort • Assure patient, family that DNR does not mean “do not treat”

  26. DNR Effects on M.D. Decision-Making • 72 yo male with advanced multiple myeloma, dementia, admitted with delirium Treatment DNR absent DNR present Blood cxs 83% 82% Central line 80% 68%* Blood transfusion 87% 75%* Dialysis 20% 9%* ICU transfer 34% 16%* Intubation 35% 5%* *p < 0.05 Beach MC, J Am Geriatr Soc 2002

  27. Patients Without DNR Directive • Avoid… • Should we try to restart your heart? • Should we shock you, press on your chest? • Should we not do anything? • “Short, Tall, Grande” discussions • Communication hygiene • Sit down • Privacy

  28. “Short” DNR Discussion (1) • Who would the patient want to communicate with physicians, make decisions if incapacitated? • Has the patient discussed care preferences? • Advance directive? Why? • What thoughts have you had about how you’d like to be treated if your condition worsened, if you became much sicker than you are now? • State your goal: treat the patient as consistent with his preferences/values as possible

  29. “Short” DNR Discussion (2) • Framing, reflecting information content from patient/family – demonstrate that you’ve listened • There’s an intervention that can be attempted if your so heart stops…From what you’ve said it sounds as if… • Share likely outcome: There’s a low/extremely low chance that you would survive and regain your current level of function • We would focus on making sure that you’re comfortable • Alleviate caregiver guilt

  30. “Tall” DNR Discussion • Ask about the patient’s story (establish trust) • How do you think you’ve been doing? • Elicit goals • What things are most important to you in your day-to-day life? • What are your priorities? Longevity, function, comfort • Caution re: quality of life discussion • Focusing on your function, comfort would mean…translate information into specific treatment recommendations (place DNR in context of care plan)

  31. Communication Documentation • Use advance care planning template in Webcis • Central location for data (phone numbers) • Describes content of communication • Assists with continuity of discussions among physicians

  32. Key Communication Elements • Trust • Encourage patients, families to talk • Demonstrate respect • Do not force decisions • Uncertainty • Make recommendations • Allow patients, families to reject recommendations • Affect • Hope • Focus on the positive Tulsky JA, JAMA 2005

  33. Summary • CPR – DNR tension for hospitalized patients • Outcomes poor for chronically ill patients • Age: weak predictor of outcome • Communication essential to understanding patient, family preferences • DNR considered in context of other treatment decisions, patients’ goals

  34. References • Quill TE. Initiating End-of-Life Discussions With Seriously Ill Patients. JAMA 2000 • Tulsky JA. Beyond Advance Directives: Importance of Communication Skills at the End of Life. JAMA 2005 • Winzelberg GS, Hanson LC, Tulsky JA. Beyond Autonomy: Diversifying End-of-Life Decision-Making To Serve Patients and Families. J Am Geriatr Soc 2005 • Ann Intern Med communication articles

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