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Every Day Across America, Helpless Dying Patients With Do Not Resuscitate Orders Are Being Resuscitated and Connected

Helpless Dying Patients With Do Not Resuscitate (DNR) Orders Are Being Resuscitated and Connected to Mechanical Ventilators . A Washington State survey discovered 31% of patients with a Do Not Resuscitate order were resuscitated at nursing homes and 13% of patients with a Do Not Resuscitate order were resuscitated at adult family homes. (1)A survey done in New York found that

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Every Day Across America, Helpless Dying Patients With Do Not Resuscitate Orders Are Being Resuscitated and Connected

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    1. Every Day Across America, Helpless Dying Patients With “Do Not Resuscitate” Orders Are Being Resuscitated and Connected to Mechanical Ventilators By Eileen M. Brady R.R.T. 1

    2. Helpless Dying Patients With Do Not Resuscitate (DNR) Orders Are Being Resuscitated and Connected to Mechanical Ventilators A Washington State survey discovered 31% of patients with a Do Not Resuscitate order were resuscitated at nursing homes and 13% of patients with a Do Not Resuscitate order were resuscitated at adult family homes. (1) A survey done in New York found that “Twenty five percent {of doctors} reported resuscitation had been attempted for at least one patient with a NH-DNR order {Nonhospital DNR order}” and “64% reported this had happened more than once.” (2) “A 53-year-old woman dying of cancer was transferred from a nursing home to spend her final hours at the hospital. But the nursing home did not forward the woman’s standing DNR order and erroneously told the hospital there was none. The woman’s shocked family arrived to find she had suffered a heart attack at the hospital, had been resuscitated, and was being kept alive on a ventilator.” (3) An elderly woman with terminal cancer lived with her daughter. The daughter ran to church leaving the woman with her adult granddaughter. The woman went into respiratory distress and the granddaughter dialed 911. The granddaughter told EMS personnel the woman was a DNR, but the granddaughter couldn’t find the paperwork. The woman was resuscitated and connected to a mechanical ventilator when she arrived at the hospital. (4) 2 The first The first

    3. Helpless Dying Patients With Do Not Resuscitate Orders Are Being Resuscitated and Connected to Mechanical Ventilators “ ‘The patient had a DNR order written in the chart but no other identifiers at bedside, so a consult service started CPR while trying to determine code status. ‘Nurse called a code on a patient who was DNR because she failed to see order in chart. ‘Resuscitation efforts took place on a patient with a DNR order because the entire chart did not accompany the patient to a diagnostic testing area. ‘Patient was off the unit for a procedure, and staff in the other department did not know patient’s code status (DNR) and called a code. ‘Patient transported off nursing unit to radiology and “coded”. Patient was a DNR, but the order was “buried” in thinned chart materials.’” (5) “The EMTs’ chart note stated, ‘Family reported patient was a DNR at home, but they didn’t have any paperwork.’ ” (6) 3

    4. The Reason DNR Patients Are Being Resuscitated The Patient Self Determination Act (PSDA) is the federal governing authority that protects a patient’s right to self determination in making health care decisions. The PSDA requires hospitals, nursing homes and all health care facilities reimbursed by Medicare and Medicaid to educate and distribute advance directives to the American people. The reason DNR patients are being resuscitated is because the Patient Self Determination Act does not mandate a protocol for the standardization of doctor authored advance directives specifically, a doctor written Do Not Resuscitate order. The PSDA definition of an advance directive is “a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State) and relating to the provisions of such care when the individual is incapacitated.” (7) The PSDA does not define the Do Not Resuscitate order as an advance directive because the PSDA only mandates standardization of patient authored advance directives such as a living will and durable power of attorney for health care. 4

    5. The DNR Revolution will prove the Patient Self Determination Act does not mandate standardization of doctor authored advance directives because the PSDA does not mandate standardization for: 1. The identification of DNR patients in nursing homes. 2. The identification of DNR patients in hospitals. 3. The identification of DNR patients who suffer from Alzheimer’s disease. 4. The education and distribution of the Nonhospital DNR Order. 5. The continuity of DNR status between health care settings. 5

    6. The Identification of DNR Patients Who Live in Nursing Homes For my data on nursing homes I went straight to the horse’s mouth, the Department of Health and Human Services Centers for Medicare and Medicaid Services (CMS). “CMS is the federal agency responsible for overseeing Medicare and Medicaid .” (8) “CMS processes an estimated 1.2 billion Medicare fee for claims, handles millions of inquiries and appeals, and conducts thousands of health care facility inspections and complaint investigations.” (9) I researched CMS nursing home violations across America and this is what I found: 6

    7. The PSDA Does Not Mandate Standardization for the Identification of DNR Patients Who Live in Nursing Homes Beacon, New York Nursing Home: CMS found 42% of residents “who had a DNR status were wearing bracelets that indicated that they wanted CPR.” (10) “Based on observation, interview and record review it was determined that the facility did not ensure that residents who did not want Cardio-pulmonary resuscitation (CPR) were properly identified.” (11) Albany, New York Nursing Home: The CMS survey found in 74% of residents reviewed, “the facility failed to have an effective system to determine a resident’s advance directives.” (12) “The color-coded bracelet systems were inconsistent or inaccurate. Unit lists were inaccurate and/or incomplete, and forms maintained in the medical record were incomplete. In addition, when a resident’s resuscitative status was included in more than one source, the information often was not consistent.” (13) The CMS survey also discovered 100% of licensed staff members interviewed on various shifts were unable “to identify which color wristband was a full code (CPR) versus DNR or how to readily identify a resident’s advance directive status.” (14) The survey also found: “two people died when the nursing home staff failed to resuscitate them even though their advance directives stated that they wished to have CPR … The report said that ‘these deficient practices placed 63 residents at the facility identified with advance directives for the facility’s CPR protocol to be at immediate jeopardy.’ ” (15) 7

    8. The PSDA Does Not Mandate Standardization for the Identification of DNR Patients Who Live in Nursing Homes A Nursing Home in Texas: CMS found 44% of DNR residents reviewed were incorrectly designated full resuscitation status. (16) “58 residents were missing necessary paperwork, such as physician orders or DNR orders. Some charts were incorrectly labeled, while others did not have the DNR status included in the care plan.” (17) “The surveyors also noted discrepancies in the nursing staffs’ approach to handling DNR matters. When interviewed about their understanding as to the action to be taken if a resident were to be found without vital signs, the nursing staff gave inconsistent responses: Two nurses indicated that they would check the chart. One CNA stated that she would go and get the charge nurse. Another CNA reported she would look to the chart to see if a red sticker was displayed to indicate DNR status. One of the nurses stated she did not know what the stickers were for.” (18) 8

    9. The PSDA Does Not Mandate Standardization for the Identification of DNR Patients Who Live in Nursing Homes Texas Continued: The CMS survey found that “the facility failed to clearly outline a DNR protocol that was properly communicated to its staff in a way that fostered an immediate DNR status determination and appropriate action consistent with that status.” (19) “CMS further argues that the breakdown of the system became more evident when Resident #4 was found to be unresponsive and the facility took no steps for emergency treatment nor initiated cardiopulmonary resuscitation (CPR).” (20) “In the case of Resident #4 the confusion was compounded when CPR was not initiated when a DNR order was not found in the file and the staff created a DNR order after the resident was deemed to have expired.” (21) 9

    10. The PSDA Does Not Mandate Standardization for the Identification of DNR Patients Who Live in Nursing Homes Indiana Nursing Home: CMS discovered 71% of residents “with advanced directives calling for either administration of CPR or no CPR in the event of cardiac or pulmonary arrest whose wishes were not correctly identified.” (22) New Hampshire Nursing Home: CMS found the facility failed “to assure that residents’ wishes concerning resuscitation were immediately available to Petitioner’s staff during an emergency situation. There were no bedside labels at the facility indicating whether a resident desired to be resuscitated nor did residents wear identification showing that they desired to be or not to be resuscitated in the event of an emergency.” (23) Arkansas Nursing Home: The CMS survey revealed the facility “failed to ensure that the code status was documented in the clinical record and readily accessible to the nursing staff; and failed to ensure that an effective system was in place to allow the nursing staff to access quickly a resident’s code status in an emergency situation.” (24) Florida Nursing Home: The CMS survey found that staff failed to provide cardio-pulmonary resuscitation to a resident. “According to the Petitioner, the failure to attempt to resuscitate Resident #3 was caused by a misreading of the resident’s chart by a nurse.” (25) 10

    11. The PSDA Does Not Mandate Standardization for the Identification of DNR Patients Who Live in Nursing Homes Wisconsin Nursing Home: CMS found the facility “failed to perform CPR after the cardiac arrest of a resident who had requested CPR.” (26) The state surveyor “stated that standard nursing practice in a nursing facility is that if anyone in a nursing facility witnesses a cardiac or respiratory arrest, the facility should have a system in place whereby all staff would immediately be aware of the victim’s elected code status.” (27) Illinois Nursing Home: The CMS survey discovered one resident died when staff did not perform CPR, although his medical record indicated full code status. CMS found that the facility failed to ensure “that physician order sheets and indicators of code status {stickers on charts, Do Not Resuscitate (DNR) sheets} agree with the residents current code status, and that staff is familiar with identifying the code status of a resident.” (28) Freeport, Illinois Nursing Home: CMS found one resident “with a full code status that did not receive cardiopulmonary resuscitation (CPR)- R1, and 24 residents with unclear indicators of code status.” (29) 11

    12. The Identification of DNR Patients in Hospitals 12

    13. The PSDA Does Not Mandate Standardization for the Identification of DNR Patients in Hospitals “Methods to identify a patient with a Do Not Resuscitate (DNR) order are incredibly varied across hospitals, ranging from written documentation practices to the use of color-coded wristbands.” (30) “This lack of standardization creates the potential for errors.” (31) A national survey of hospitals, published in 2007, discovered: “More than 70% of respondents recalled situations when confusion around a DNR order led to problems in patient care.” (32) One state survey of hospitals found that “87% of the respondents used colored wristbands, but there was no standardization of colors among them and at least eight different colors were used to designate DNR.” (33) Another state survey of hospitals using color coded wristbands “found nine different colors for do not resuscitate.” (34) The Pennsylvania Patient Safety Authority in 2005 released a patient safety advisory regarding using colored wristbands. “This advisory brought attention to an incident in a Pennsylvania hospital in which clinicians nearly failed to rescue a patient who had a cardiopulmonary arrest because the patient had been incorrectly designated as Do Not Resuscitate (DNR).” (35) “ 13

    14. The PSDA Does Not Mandate Standardization for the Identification of DNR Patients in Hospitals “In December 2004 the issue of patient wristbands made headlines in Florida, when hospitals using yellow DNR wristbands … reported several near-misses among patients wearing yellow Lance Armstrong Livestrong bracelets. Given recent estimates that nearly 1 in 5 Americans wears these bracelets to support people living with cancer, even safety-minded journals and national newspapers have highlighted the issue.” (36) Many other self-help organizations now issue wristbands in a variety of colors as well, creating a potential hazard for any person wearing one in the hospital.” (37) Standardization is known to prevent patient care mistakes. But “without national regulations or standards, the possibility remains that one safety hazard (advance directives on a paper chart distant from a patient’s room) may be traded for another hazard (front-line providers interpreting a colorcoded wristband incorrectly).” (38) 14

    15. The Identification of DNR Patients Who Suffer From Alzheimer’s Disease 15

    16. The PSDA Does Not Mandate a Safety Standardization for the Identification of DNR Patients Who Suffer From Alzheimer’s Disease Confused Alzheimer’s patients can remove and/or put on a colored wristband. A safety solution for Alzheimer’s patients, according to the authors of the Alzheimer’s book, The 36 Hour Day, is “a bracelet that is securely fastened (so the patient cannot take it off). ” (39) A 2008 survey found “as many as 5.2 million Americans are living with Alzheimer’s disease.” It also “estimates that 10 million baby boomers will develop Alzheimer’s disease.” (40) I found this story written on December 7, 2007 regarding a daughter’s concern upon learning blue colored wristbands were being used to identify DNR patients. The daughter, whose mother has Alzheimer’s and lives in a nursing home, wrote: Clearing out her closet I found her ‘stash’ of found objects (all hers according to her). 3 water pitchers belonging to others. 1 man’s hat I have no idea where it came from, but it had her name on it in magic marker, and one name band that had the previous (deceased) resident’s name on it. I clean out her closet and chest of drawers every time I go. Now I wonder in the above situation, if she were to ‘find’ a blue band and put it on because it is a pretty color???.... (41) 16

    17. The Education and Distribution of the Nonhospital DNR Order 17

    18. The “Nonhospital DNR Order” is Required By 911 EMS Providers A Do Not Resuscitate order written and signed by a doctor in a hospital or nursing home becomes null and void the minute the patient is discharged from the hospital or nursing home. A hospital or nursing home DNR order is not legal and not valid in community settings such as grocery stores, churches, or even in the patient’s own home. The only way to ensure continuity of DNR status when a DNR patient leaves a hospital or nursing home is for the patient to be discharged with a Nonhospital DNR Order signed by their doctor. The Nonhospital DNR Order is a legal Do Not Resuscitate order that instructs 911 EMS health care providers not to resuscitate the patient. By law EMS providers are only permitted to honor a Nonhospital DNR Order signed by the patient’s doctor. 18

    19. The PSDA Does Not Mandate Standardization for the Education and Distribution of the Nonhospital DNR Order A survey done in New York discovered 54% of physicians did not distribute the official New York State Nonhospital DNR form to their Do Not Resuscitate patients. (42) The authors of the survey state “that this may be why prehospital resuscitations were attempted despite the DNR order.” (43) A survey done in Washington revealed that “60% {of doctors} did not know that Washington State requires an emergency medical service (EMS) -specific DNR order authored by a physician.” (44) The same survey also found: “Seventy nine percent {of doctors} did not know that patient- authored advance directives apply only in hospitals and medical offices.” (45) In Massachusetts, “the state estimates between 13,000 and 15,000 people have used the {EMS Comfort Care/DNR} bracelet, but the program has not been widely publicized and many patients and doctors are not even aware of it.” (46) 19

    20. Continuity of DNR Status 20

    21. The PSDA Does Not Mandate Standardization for the Continuity of DNR Status A CMS survey revealed in 54% of DNR residents reviewed there were delays of up to thirty days in the continuity of DNR status when a patient was admitted to a long-term heath care facility with a valid Nonhospital DNR Order. (47) An example: A resident was admitted to the facility with a Nonhospital DNR Order. “The resident’s admission orders were signed (not dated) by the physician, although the advance directives section was left ‘blank’.” (48) CMS found that the resident was a full CPR status for 22 days after being admitted with a valid Nonhospital DNR Order. (49) “The NP {nurse practitioner} stated that ‘a lot’ of resident came to the facility with nonhospital DNRs. She stated that she could ‘not accept that…have to do our own paperwork.’ … She said she would communicate the resident’s request for DNR status to the doctor, but that only a physician could write a DNR order, and acknowledged the potential for delays and gaps in the continuity of DNR status.” (50) The director of social work (DSW) was also interviewed and “admitted there was no system in place to ensure continuance of a hospital DNR, or to obtain a DNR order when there was evidence of a prior desire for DNR status. She acknowledged delays occurred ‘if they (residents) come with a hospital DNR- in order to be okay here, it has to be okayed by our doctor.’ The DSW added the physician usually visited the facility every Thursday.” (51) 21

    22. The PSDA Does Not Mandate Standardization for the Continuity of DNR Status A second example: A resident transferred to the facility from another long-term health care facility had a valid Nonhospital DNR Order; however, review of the resident’s medical record revealed that the resident remained a full code (CPR status) for more than one month after the resident was admitted. (52) When the medical record was reviewed, CMS found “no documentation of any discussion with the resident’s health care proxy or an explanation for the 1 month delay in obtaining a DNR order.” (53) A third example: A resident was admitted to the facility with a valid Nonhospital DNR Order. “The social worker also documented that the resident and her health care proxy understood the resident ‘had a DNR order, (and) wish this to continue.’ ” (54) CMS found: “This resident remained a ‘full code’ (CPR status) for 23 days after requesting DNR status.” (55) 22

    23. Violations Against The American People 23

    24. Violations against the American People Because the PSDA Does Not Mandate Standardization of the Do Not Resuscitate Order It is a violation against a DNR patient’s right to self determination when doctors do not know their state laws regarding Nonhospital DNR Orders. The Nonhospital DNR Order is required by EMS health care providers and must be signed by the physician and distributed to all DNR patients. It is a violation against a DNR patient’s right to self determination when there are delays of up to 1 month in the continuity of DNR status when a patient is admitted to a long-term health care facility with a valid Nonhospital DNR Order. It is a violation against Alzheimer's patients’ right to self determination to use a colored wristband to identify “DNR” status; Alzheimer’s patients can remove a colored wristband. It is a violation against all patients’ right to self determination when “location determines whether the patient’s preference {for CPR} is respected.” (56) It is a violation against a DNR patient’s right to self determination when health care providers pound on their chest, shock them with electricity and insert an artificial tube into their lungs and connect them to a mechanical ventilator. 24

    25. Revolution Solutions 25

    26. We Need One DNR Bracelet That All Hospital, Nursing Home, Assisted Living, Hospice and EMS Health Care Providers Can Jointly Honor: “ ‘The multitude of ways used to differentiate between residents who have DNR orders and those who do not and the inadequacy of many of these methods clearly point to the need for clear, unequivocal, and rapid determination of a resident’s preference regarding resuscitation. The effectiveness of CPR depends on rapid response, which allows no time to leaf through a medical record to determine resident wishes.’ ” (57) It also allows no time for 911 EMS providers to “look around” a private home trying to find the Nonhospital DNR Order. In addition, the increasing turnover rate with hospital and nursing home staff as well as “ ‘the use of personnel from external labor pools intensify the need to have mechanisms in place that facilitate immediate identification of a resident’s CPR status in the event of an arrest. Such mechanisms both protect against unwanted resuscitation for people with DNR orders and ensure appropriate action for those without them.’ ” (58) 26

    27. We Need One DNR Bracelet That All Hospital, Nursing Home, Assisted Living, Hospice and EMS Health Care Providers Can Jointly Honor: “There are approximately 1.6 million residents in the 18,000 nursing homes in the U.S.” (59) Nursing home advance directive complaints rose 102% nationwide from 1996 to 2006 according to the National Ombudsman Reporting System. (60 and 61) “A significant obstacle to implementing ADs {advance directives} is that they may not move with the patient to across care venues.” (62) “Transfer across sites of care is common near end of life, with approximately 25-30% of Americans cared for in three or more settings (home, hospital, nursing home) in their last months of life. Dying patients, in particular, are at risk for transitions across settings.” (63) “A study conducted by the American Medical Directors Association found that advance directives and code status were absent in 81% of transfers.” (64) One DNR bracelet “may be especially useful for home care situations that involve multiple caregivers, to ensure that all are informed about the patient’s decision. Further, seriously ill people who have no family to represent their wishes may find the use of the bracelet reassuring if they are living independently. ” (65) 27

    28. Revolution Solutions Vote to Amend the Patient Self Determination Act to Include: 1. Standardization of the Do Not Resuscitate Order. 2. One DNR Bracelet for all Health Care Providers. 3. A Safety Standardization for the Identification of Alzheimer’s Patients. 4. The Education and Distribution of the Nonhospital DNR Order. 5. Continuity and Identification of DNR Status Between Health Care Settings. 28

    29. I Found Something While I Was Doing My Research While surfing the web I came across a Do Not Resuscitate order called “Medical Orders For Life Sustaining Treatment (MOLST)”. I decided to check out the MOLST Do Not Resuscitate order and learned Dr. Patricia Bomba M.D. “spearheaded the program as Vice President and Medical Director of Geriatrics at Excellus BlueCross BlueShield.” (66) “Excellus BlueCross BlueShield, headquartered in Rochester, NY, is part of a $5 billion family of companies that finances and delivers heath care services across upstate New York and long-term care insurance nationwide.” (67) The MOLST form itself is four pages and includes DNR orders, but I also noticed four additional pages were attached to the MOLST. The four additional pages are called “ ‘Supplemental’ Documentation Forms For Adults” and they include clauses and exceptions relating to the mentally challenged, prisoners, medical futility and no surrogate situations. (68) While reading the forms I noticed a statement under therapeutic exceptions that says: “For patient/resident with capacity who would suffer immediate and severe harm by a discussion about DNR.” (69) 29

    30. “For Patient/ Resident With Capacity Who Would Suffer Immediate and Severe Harm By a Discussion About DNR” This statement allows a physician and surrogate the power to write a DNR order on a patient with capacity and not tell the patient that an order not to resuscitate them has been issued. To view this statement, visit the website. It’s on page 3 under Therapeutic Exception 2A: www.ohsu.edu/ethics/polst/programs/forms/ny-supplemental-adults.pdf I showed this statement to my medical friends and not one of us could think of an example of a patient who has capacity who would suffer immediate and severe harm from a conversation so I decided to call Excellus BlueCross Blue Shield and ask. I called and scheduled a telephone conference call with Dr. Patricia Bomba. “Dr. Bomba’s collaborative work with NYSDOH {New York State Department of Health} on health policy and her legislative advocacy for the MOLST Program aims to facilitate establishment of MOLST as a statewide program. As a result of these efforts, the MOLST Pilot Project Legislation revised the Non-hospital DNR Law. The revision permits the NYS Department of Health to authorize use of the MOLST form in lieu of Non-hospital DNR.” (70) 30

    31. My Conversation With Dr. Patricia Bomba My question: I noticed on page two of the Supplemental Documentation Form For Adults in Exceptional Circumstances that it says, “For patient/resident with capacity who would suffer immediate and severe harm by a discussion about DNR.” Who is that statement for ? Dr. Bomba: “It’s for a rare exception for someone who says, ‘I don’t want to talk about it.’ ” Can you give me an example? I don’t understand who would hav e capacity and would suffer severe and immediate harm by a discussion. “Well, it’s very very rare exception and it covers who just doesn’t want to talk about the DNR or those who would become upset by it.” Is that statement for the mentally challenged? “Oh no.” 31

    32. “For Patient/ Resident With Capacity Who Would Suffer Immediate and Severe Harm By a Discussion About DNR” So that statement is not for the mentally challenged ? “No. It’s for people who don’t want to talk about the DNR. It’s very, very, rare and it was only put in to cover every possible situation.” I took the form to work and none of us could figure out who would have capacity and suffer immediate harm and injury from a conversation. We didn’t know if it was for the prisoners? “Oh no, no, no . It’s not for the prisoners.” So it’s not for the mentally challenged or the prisoners ? “It could be applied to the OMH {Office of Mental Health} patients more than the prisoners, and more for OMH patients than OMRDD {Office of Mental Retardation and Developmental Disabilities } facilities, but no not the prisoners and even if it is applied they have to fill out the reasons why it is being used.” 32

    33. “For Patient/Resident With Capacity Who Would Suffer Immediate and Severe Harm By a Discussion About DNR” Why would it be used more for the OMH patients than OMRRD facilities? “Not every situation can be totally covered by the MOLST form. There are many situations for example when there is no healthcare agent, no living will and medical futility. These situations would apply more to OMH patients. This allows for every situation to be covered, but it is a very, very, rare instance that it is used and it really is just for someone who just doesn’t want to talk about it.” So it is used for the mentally challenged? “It can be applied to the OMH’s. I guess I’m not making myself clear and I don’t know how else to put it that you would understand it. Do you have any other questions?” Does the MOLST have a bracelet? “No.” Are there any plans for a bracelet? “No. We don’t think people want to wear a bracelet. We think we can train the people to keep the MOLST on the refrigerator.” 33

    34. After my conversation with Dr. Bomba I decided to research CMS violations regarding capacity and the MOLST form. And this is what I found: 34

    35. CMS Violations Blossom Health Care Center, Rochester, New York: “Resident #11 was admitted to the facility on 8/28/07 with diagnoses including schizophrenia and diabetes. An 8/28/07 Social Work note indicated the resident was alert and oriented.” (71) “The MOLST was completed by the Social Worker and the resident’s Health Care Agent and was signed by the physician indicating that the resident was to be a DNR.” (72) On admission the resident was noted to be alert and oriented, but on the MOLST “the section indicating that the resident lacks capacity includes that the resident is cognitively impaired ‘indefinitely’.” (73) The MOLST form also included medical orders signed by the physician that included no artificial hydration or nutrition via tube feeding, no antibiotics and only allowed the patient to be hospitalized with restrictions. (74) 35

    36. Resident #11 Continued CMS found: “The MOLST was not signed by a concurring physician determining lack of capacity. There was no documented evidence that advance directives were discussed with the resident. The physician signed the MOLST on 10/3/07 and 12/5/07 indicating that the code status was reviewed. Again, there was no documentation indicating that the MOLST was discussed or reviewed with the resident.” (75) “When interviewed on 1/9/08 at 12:00 p.m., the resident said she had not been consulted regarding her wishes for advance directives. When asked about her current MOLST and if these were her wishes, the resident stated, ‘Rip that paper up that says I don’t want help.’ ” (76) “An interview with the physician on 1/9/08 at 12:15 p.m., revealed that advance directives were not reviewed with the resident upon admission or on 10/03/07 or 12/05/07.” (77) “The physician indicated that she did not remember why the resident’s health care agent had completed the MOLST upon admission. The physician said that the resident was alert and oriented and able to make her needs known and that she would review advance directives with the resident.” (78) 36

    37. CMS Violations Continued Jewish Home of Rochester, Rochester, New York: “Resident #20 was admitted to the facility on 4/26/05. The 05/05/05 MOLST indicates the resident has decision-making capacity and gave verbal consent for full Cardio Pulmonary Resuscitation (CPR).” (79) “The 04/04/06 MOLST indicates that full CPR status was discontinued, the resident is a DNR, and does not have decision-making capacity. There was no supplemental MOLST with a concurring physician’s signature.” (80) “When interviewed on 10/10/07 at 1:00 p.m. and 10/11/07 at 7:30 a.m., the Medical Director agreed there was a problem with the MOLST, and that the facility was reviewing and revising the records.” (81) 37

    38. CMS Violations Continued Maplewood Nursing Home Inc, Webster, New York: “Resident #14 was admitted to the facility on 1/3/08 and had a diagnosis of metastatic cancer of the stomach. A Health Care Proxy form, dated 12/7/07, denoted that the health care agent should take effect only when and if the resident is unable to make his own health care decisions.” (82) The Admission Assessment “denotes the resident’s cognitive skills for daily decision making as modified independence.” (83) “The Social Worker’s (SW) note of 1/3/08 included that the Director of Nursing and Medical Director met with the resident’s family to review Resident #14’s medical history. The family was provided information about Medical Orders for Life Sustaining Treatments (MOLST), with instructions to discuss it as a family. The note also included that the resident’s status was full cardiopulmonary resuscitation (CPR) until further instruction by the family.” (84) “The physician’s admission note, dated 1/4/08, also included that the resident was a full code (CPR is to be administered). There was no documentation of any discussion with the resident of his advance directive wishes.” (85) “A 1/8/08 Social Work note revealed that the family decided to change the resident’s status to Do Not Resuscitate (DNR), but had not discussed this with the resident.” (86) “ 38

    39. Resident #14 Continued “The MOLST form, dated 1/08/08, and signed by the proxy, specifies the resident will be a DNR. There was no documented evidence that the resident lacked capacity to make his own healthcare/advance directive decisions.” (87) “When interviewed on 3/7/08 at approximately 11:30 a.m., the SW {social worker} stated that Resident #14 does not have a concurring physician signature on the MOLST verifying that he lacks capacity to make decisions. The SW also stated that if the attending physician had discussed resuscitation wishes with the resident, it would be in the progress note.” (88) 39

    40. CMS Violations Maplewood Nursing Home Inc, Webster, New York: “Resident #11 was admitted to the facility in April 2007. On 4/25/07, the attending physician signed the MOLST form indicating that the resident was not to be resuscitated. The MOLST also indicated that the resident lacked capacity. There was no concurring physician signature to verify lack of capacity.” (89) “The resident was hospitalized from 1/4/08 to 1/8/08 for surgical repair of a fractured hip. On 1/22/08, another MOLST form was signed by the attending physician and co-signed by the Health Care Proxy indicating the resident lacked capacity to make decisions. Again, there was no concurring physician signature to verify the resident did not have decision-making capacity.” (90) “When interviewed on 3/7/08 at about 8:20 a.m., the Assistant Director of Nursing confirmed that Resident #11 has decision making capacity.” (91) 40

    41. CMS Violations Blossom Health Care Center, Rochester, New York: “Resident #12 was admitted to the facility on 11/17/06 with a diagnosis of dementia. The 12/27/06 MOLST indicates the resident does not want to be resuscitated (DNR) and does not have decision making capacity. There is no concurring physician signature.” (92) “When interviewed on 1/9/08 at 3:00 p.m., the Nurse Manager was not sure whose responsibility it was to obtain a concurring physician signature.” (93) Resident #8 was admitted to the facility with a diagnosis of dementia. The 11/20/07 Minimum Data Set (MDS) Assessment indicates that the resident has moderately impaired cognitive skills for daily decision making.” (94) “ The MOLST completed and signed by the physician on 1/24/07 indicates that the resident does not have capacity. There was no concurring signature from a second physician.” (95) 41

    42. MOLST UPDATE On July 8, 2008 New York Governor David Paterson signed into law a bill that makes the MOLST Program permanent and statewide. (96) 42

    43. Revolution Solution Please Vote Against Any and All Insurance Companies From Sponsoring and/or Endorsing A Do Not Resuscitate Order 43

    44. Revolution Solution For The Citizens of New York Please Vote That The Therapeutic Exception (“for patient/resident with capacity who would suffer immediate and severe harm by a discussion about DNR”) Be Stricken from the MOLST Form, Pending a Thorough Investigation Into Its Context. 44

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