Spotlight Case July 2003

1. Spotlight Case July 2003 Code Status Confusion webmm.ahrq.gov

2. Source and Credits • This presentation is based on the July 2003 AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available through the Web site • Commentary by: Bernard Lo, MD, University of California, San Francisco; James A. Tulsky, MD, Duke University Medical School • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Tracy Minichiello, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Appreciate challenges of determining goals of care in hospitalized patients • Understand common misconceptions about CPR • List typical mistakes physicians make when discussing advanced care planning • Recognize steps physicians and health care systems can take to improve advanced care discussions

4. Case: Code Status Confusion A 60-year-old woman with a history of severe asthma without prior intubations presented to the ER with shortness of breath. On physical examination, her BP was 145/85, HR 85,O2 sat 94% with a respiratory rate of 22. Her lung exam revealed diffuse-end expiratory wheezes and decreased breath sounds at the bases. Despite a long-standing relationship with a PCP, the patient had neither designated a health care proxy nor completed a living will prior to admission.

5. Advanced Directives • 75% of patients who present to the ER do not have advanced directives • Even fewer in absence of terminal diagnosis • When completed, advanced directives are often unavailable upon hospitalization or are difficult to interpret • Hospital-based physicians often discuss code status with patients they have not met previously Ishihara KK, et al. Acad Emerg Med. 1996;3:50-3.

6. Patients’ Preferences Regarding CPR • 30% of patients with serious underlying illness do not want resuscitation • Physicians cannot accurately predict patients’ preferences without asking them Hofmann JC, et al. Ann Intern Med. 1997; 127:1-12.

7. Case (cont.): Code Status Confusion Upon admission, the intern spoke with the patient about code status. The patient stated that she “would not want to be on a tube to breathe.” About CPR, she did not want “shocks to the heart or pressing on my heart.” She said if her breathing continued to be this difficult and she could not live independently, she would rather not survive. The intern interpreted these statements as indicating the patient’s desire for DNR status, and called the resident to discuss it, but a DNR form was not completed at that time.

8. Common Features of Code Status Discussions • Use of vague language • “Would you want your life prolonged?” • Use of dire scenarios • Only 50% of MDs present scenarios with reversible conditions • Failure to elicit patient concerns and discuss goals of care • Rarely clarify “small chance” recovery, poor quality of life Tulsky JA, et al. Ann Intern Med. 1998;129:441-449.

9. Common Features of Code Status Discussions • Domination of discussion by physician • Physicians speak nearly three-fourths of the time • Use of medical jargon • Without confirming patients understanding Tulsky JA, et al. J Gen Intern Med. 1995;10:436-442.

10. Do Patients Understand CPR? • Survey results: patients have misconceptions even after discussions: • CPR survival estimated to be 70% (in reality is 10%-15%) • 26% could not identify features of CPR • 37% thought ventilated patients could talk • 20% thought ventilators were O2 tanks • 20% thought people on ventilators were in a coma Fischer GS, et al. J Gen Intern Med. 1998;13:447-454.

11. Case (cont.): Code Status Confusion A few hours after admission, the patient had sudden respiratory failure leading to pulseless electrical activity (PEA) arrest. As there was no DNR form in the chart, the nurse called a code and CPR was initiated. The code team found the intern’s initial assessment, which stated the patient’s preference for no resuscitation or intubation efforts.

12. Case (cont.): Code Status Confusion The resident had discussed the case briefly with the intern (including her interpretation that the patient wished to be a DNR), but neither the resident nor the attending had discussed code status with the patient. At this time, the patient’s blood pressure was 90/palpable, heart rate was 40 and an O2 saturation was 92% with assisted bag-mask ventilation.

13. The Code Status Dilemma • Documentation—No code status documented in chart; therefore, code initiated • Autonomy—Patient had expressed wish to be DNR to intern on admission • Beneficence—Team knew prognosis of witnessed arrest from asthma exacerbation was good • Informed decision making—Team concerned patient was not fully informed when she requested to be DNR on admission • This is the only ethical justification for overriding a DNR order Lo B. Promoting the patient’s best interests. In: Resolving ethical dilemmas: A guide for clinicians (2nd ed.). 2000:30-41.

14. Case (cont.): Code Status Confusion The patient did receive cardiopulmonary resuscitation, including medications and chest compressions. In an effort to respect her preference to avoid invasive ventilation, she was started on noninvasive bi-level positive airway pressure (BIPAP) ventilation. Spontaneous respirations returned with BIPAP, and the patient was stabilized.

15. Case (cont.): Code Status Confusion The next day, the patient was alert and able to express her thoughts about the events of the previous night. She had not realized that intubation could be a temporizing measure—she thought it meant permanent respiratory support. She had thought the discussion was about whether she would want to be kept alive if she was “a vegetable.”

16. Case (cont.): Code Status Confusion Furthermore, the patient said that she had not realized that resuscitation attempts could be successful. After her experience, she stated that she did want aggressive interventions for reversible causes. Her code status was changed to full code.

17. Tips for Discussing Advanced Directives • Do more listening and less talking • Elicit patients’ values and overall goals of care—match interventions with these goals • Use simple language • Make clear the alternative to CPR is death, and express the likely survival after CPR. • Distinguish situations where outcomes are better, such as in the OR or during conscious sedation for procedures

18. Tips for Discussing Advanced Directives • Ask about preferences in scenarios with uncertain outcomes • i.e., successful cardiac resuscitation with resultant severe anoxic brain injury • Assess the patient’s understanding • Especially if decision is contrary to what would be expected in similar patients • Reassess the patient’s goals of care at every hospitalization

19. Recommendations for Hospitals and Educators • Standardize the DNR order sheet • Separate authorization for CPR, intubation, and vasopressors • Consider including other life-prolonging interventions (i.e., tube feeds, antibiotics, dialysis) that may be instituted in patients who will not receive CPR

20. Recommendations for Hospitals and Educators • Teach residents and medical students how to elicit patients’ preferences and goals of care • Do not rely on lectures alone • Observe trainees conducting advanced directives discussions and give feedback • Consider role playing, video-taped sessions, and standardized patients • Provide opportunities for trainees to observe seasoned clinicians discussing goals of care Tulsky JA, et al. Arch Intern Med. 1996;156:1285-1289.

21. Recommendations for Hospitals and Educators • Promote interactions between hospital-based and primary care physicians • Ideally, hospital-based housestaff and hospitalists would talk to these physicians before writing DNR or DNI orders Lo B. Am J Med. 2001;111:48-52.