Transcript DNRpresentations - Northeast Iowa Family Practice

Negotiating the Land Mines of
Do Not Resuscitate Orders
Francis Degnin M.P.M., Ph.D.
Department of Philosophy & World Religions
University of Northern Iowa
[email protected]
Objectives
1. Describe legal and ethical issues dealing with DNR’s in various
circumstances. i.e.:
a.
b.
c.
d.
Patient/family conflicts, i.e., the vague “do everything” directive
Dealing with a DNR request after a suicide attempt
Unusual requests (partial codes, etc.)
Conflicts between patient autonomy and medical
appropriateness.
2. Describe hospital policies and procedures for dealing with:
a.
b.
Who is responsible for code status
DNRs existing prior to surgeries.
3. Discuss strategies and issues for talking with patients about DNR orders.
Case 1: When Patient and Family
Wishes Conflict?
Your patient is male, elderly, in poor health, in
the ICU for what is likely a terminal admission.
While he doesn’t want to die prematurely, he
explains that if his heart were to stop, he would
just want to be kept comfortable and allowed
to die. He requests a DNR order. The family
adamantly objects, insisting that everything be
done.
Questions?

What are your concerns?

What are the ethical issues?

What are the practical issues?

What do you want to ask?
Issues

Is the patient competent/decisional?

Is the patient consistent in her/his request?

Is the likelihood of a code immediate?
◦ Is there time to try and bring the family around?

What is medically appropriate?

What is the relationship with the family?

What is the law?
The Law: Cruzan 1990
Competent adult patients, either directly or via
a surrogate, have the right to refuse medical
treatments, even if that refusal leads to their
death.
To treat a person against their will may be
considered assault and battery and a violation
of their civil rights.
(Exceptions for ER and Paramedic circumstances)
When the Family Objects?

We normally accord a certain respect to
the family of a dying patient.

That doesn’t mean their wishes should
override those of the patient.

So, in a case where the patient’s wishes
are clear, why do many health care
institutions listen to the family and not
the patient?
Cynical View: Fear of Lawsuits
Some hospitals take the position that, if
there is any sort of conflict, treat—that
will play better both in the media and
before a jury.
“Peg him, trach him, ship him…”
Long Term Care View: If the patient
becomes non-decisional…

The family may need to make future
decisions.

If we damage that (trust) relationship, it
may become harder to promote a good
outcome for the patient.
What Actually Happened?

The patient was in the ICU for week
before he coded.

He was still a full code at the time.
Case 1: Conclusion

If the patient is competent, it is his/her decision.

If the risk of a code is not immediate, it is appropriate
to ask the patient for some (limited!) time to negotiate
with the family and help ease their concerns.

Ideally, involve the patient in the conversation with the
family.

This is a great case for ethics committee involvement—
they can back up the patient, the physician, and help
with the family.
Dysfunctional Motivations: Family
1. Guilt—some fear of what they will feel if
they don’t believe that they have “done
everything” to save their loved one.
2.
“Miracle thinking”, the belief that they
have to give God every chance to
perform a miracle.
Dysfunctional Behaviors: US
3.
We can be our own worst enemy—
sometimes, even when we know the patient it
going downhill, we wait and hope for the best,
only discussing a DNR when it becomes
absolutely necessary.
- This does not allow the family to prepare
emotionally.
- They may feel ambushed.
- Undermines trust
Dysfunctional Behaviors: US
4.
Sometimes we allow an inappropriate
family member to act as decision maker
so as to “avoid” conflict.
This can create “trouble” down the
road.
5.
Confusing a DNR with Do Not Treat.
Tips: Dealing with Guilt?
Conversation—we may need to get at the
reasons for what they’re asking.
Family members sometimes develop
“rationales” for gut emotional
reactions…without realizing their real
motivations.
Pastoral Care and Ethics can help.
Reorienting the Conversation
Get the family to focus on the patient’s wishes…i.e.:
“I know that you love your father and want the best
for him. But please understand, this isn’t about what
you want for your father, it’s about what he would
want for himself. Can you think of things that your
father has said that suggest what he might want
here?”
Invite them to tell stories (including with one another)
about their loved one…this can be a powerful tool.
False Choices = False Guilt
If I present a DNR order as a neutral choice, many will perceive it
as “I want your permission to give up on your loved one” or “I
want your permission to kill your loved one.”
Even the language, “Do Not Resuscitate” Order is deceptive—it
implies, falsely, that we could resuscitate the patient, but choose not
too.
This may leave the surrogate with a false sense of guilt.
We know that, in reality, a “DNR” is a procedure which we attempt,
but like all such procedures, often fails.
Consider the language of a “DNAR” Order—”Do Not Attempt
Resuscitation”—it’s more accurate and less likely to inspire guilt.
Minimizing False Guilt
If a DNR is medically appropriate, don’t present
it as a “neutral” choice to the decision maker.
Make it clear why a code is medically
inappropriate (extreme suffering with little/no
chance for a positive outcome.)
Explain why you don’t want to put their loved
one through this kind of suffering. Unless they
object, offer it as information, not as a choice.
The “Do Everything” Directive
Again, don’t offer a treatment as neutral which is not medically appropriate.
Start by strongly affirming their directive, then add detail:
“We are doing everything. We will continue to do everything that is
medically appropriate, everything that has a chance to help your mother.”
It might then be appropriate to offer a detailed discussion of the risks and
side effects of a code, followed by something like:
“Your mother is so sick that, if her heart were to stop and we were to
code her, it would only result in a painful, difficult death. If this were my
mother, I’d want her to die as pain free and as peacefully as possible. At
this point, a code would merely extend her dying, not save her life.”
I’ve even sometimes (though not often…it’s a judgment call) noted how, in
some cases, a family who wanted to “do everything” to avoid one form of
guilt was then left with the guilt of having put their loved one through a
horrible death.
Miracle Thinking?

While I would never deny that miracles are
possible, for many, this is really a form of denial.

However, whether it is a form of denial or a
sincere religious belief, doesn’t always matter.
Miracle Thinking: Solutions

Get pastoral care involved.

Allow them to talk, to tell their stories, reorient towards the patient’s
wishes.

Explain that while God has her/his own ways, we can only act in ways
which are medically appropriate.

Depending upon the circumstances, I may raise the following questions:
1.
2.
3.
If God really wants to perform a miracle, does he/she really need our help?
Isn’t putting a person on a machine is already “playing God.” If so, might not
the act of taking them off (or deciding on a DNR) be to admit our limitations
before God, allowing God (or nature) to take it’s course?
If the patient believes in heaven, and there is nothing left we can do to return
them to a reasonable state of health, why should we keep them suffering
rather than allowing them their heavenly reward?
Avoid “Ambushing” the Family
1.
Develop a relationship with potential decision makers before the
crisis event.
Talk early, talk often. For example, revisit Advanced Directives
during a patient’s yearly flu shot.
2.
Enlist the family in the diagnostic process. Time can be your ally:
Talk to them early about diagnostic indicators which they might also be
able to observe. For example, for a patient on a respirator, show them
the
pressure and the O2 levels, explain how (and how much) the levels should
be
going down if the patient is making progress over time. If they don’t go
down
over several days, the family can see for themselves that the patient is not
progressing.
Talking about DNRs
3. Avoiding beating around the bush…be sensitive, but
make sure they understand.
4. Be sensitive to the fact that some patients may fear
abandonment if they don’t “do everything” they believe
their physician wants.
or
Clarify that “do not resuscitate” does not mean “do not care”
“do not treat.”
-
Explain that it’s just a single procedure which does not appear
medically appropriate (or is against patient wishes.)
Be clear that you will still be involved in their care and
comfort.
Confusion: DNR and Do Not Treat

A DNR is only a single procedure.
◦
◦

For example, a patient who is a DNR may be intubated for a
pulmonary edema.
The intubation can also be refused. But if it is not part of an
actual code, it does not violate the DNR.
Levels of Care/Treatment (One model)
1.
2.
3.
4.
Aggressive Treatments/Full Code
Supportive/aggressive/No Code
Supportive care
Comfort Care
Language Counts

In one case, an ICU nurse was doing an
excellent job of explaining the “DNR” does not
mean “do not treat”. But she kept referring to
refusing the code as refusing “heroic measures.”

“Heroic” sounds like a good thing, so refusing it
sounds like a bad thing.

Instead, speak of refusing “aggressive measures.”
Case 2: Medically Inappropriate Code
Status: Fearful Patient
Your patient is as 76 y/o male presenting with extreme
shortness of breath and generally poor health. The
DPAHC is held by his brother, also elderly and disabled,
who is unable to come to the hospital. In phone
conversations, the brother merely directs us to do
“whatever we think is best.” Just before going on the
ventilator, the patient was told that he would be unlikely
to ever come off. He told the nurse that he wanted
“everything done.” He appeared quite fearful. Two ICU
nurses and the ICU attending expressed concern over
the fact that the patient was a full code—even to the
degree of asking why a “code” was so different than
most other treatments.
Ethical Question
Why do we allow patient’s to demand a
code when it is clearly “futile” care?
AMA Code 2.035 Futile Care
“Physicians are not ethically obligated to deliver care
that, in their best professional judgment, will not
have a reasonable chance of benefiting their
patient. Patients should not be given treatments
simply because they demand them. Denial of
treatment should be justified by reliance on
openly stated ethical principles and acceptable
standards of care…” (emphasis added, 20062007)
Futile Care?

Confusion over the definition

NOT: No chance (impossible standard)
(AMA code acknowledges that this concept of futility
cannot be meaningfully defined.)

Refers to there being no “reasonable” chance of
meeting the goals of care.

Greek Myth: Futilis
Medical Appropriateness: Reversed?
Physicians are not required to offer treatments
to patients which, according to the best
evidence and their best medical opinion, offer
little hope for achieving the goals of care.
Yet in the case of a “code”, this practice is often
reversed—we seem to require permission for a
DNR even when the treatment offers no
reasonable hope of benefit.
Why?

Positive Reason:
◦ Death is permanent, so stabilize and decide later.
(As with the ER and Paramedic exceptions, we are unable to
access a patient’s competency and wishes.)
◦ Only applies if the patient wishes are unclear prior to the code.

Negative Reason:
◦ Fear of lawsuits (who will be around to sue?)
◦ The AMA may not be there to back you up in the courtroom!
◦ Marketing (bad publicity)
Impossible Situations?

Physicians are not required to perform procedures or treatments
which are medically futile.

But there is a risk—anyone can try to sue.

Get the ethics committee involved.

Hospice?

Get a second opinion if appropriate.

Offer to transfer the patient if someone else will take over care.

Not everything can be fixed.
Tragic Choice?
Assume that the patient’s wishes are unclear and the
family insistent.
You’ve made some progress limiting inappropriate
treatments.
You may choose to stay on the case, even with moral
discomfort, because transferring the patient may result
in losing all the progress and trust thus far earned with
the family.
Half a loaf is better than no bread
Moral/Psychological Discomfort?

Medical professionals are usually
compassionate people.

They don’t enter the profession because
they want to watch people suffer.

So how does one deal with having to
watch a patient suffering unnecessarily on
one’s watch?
Options?

In some cases, one can ask to be excused
from the care of a particular patient.

Some health care professionals find other
specialties within the profession.

Some, sadly, numb themselves.
Another Option

Accept and make a space to feel that discomfort.

Ask, what has it to teach me?

Take the fact that one sometimes goes to bed
uncomfortable, questioning one’s involvement or
decisions, as a sign that you’re awake, that you’re at least
facing and trying to learn from the concrete demands of
dealing with human needs.

Take a certain kind of peace in the fact that you are
sometime uncomfortable—and therefore awake and
growing.
Case 3: Partial DNRs?
A 90+ y/o woman presents with a variety of
medical problems, including COPD. She is on
home O2 and has come in for shortness of
breath. She requested a DNR, with one
exception. She wants to allow intubation so
long as it was expected to be short term. She
was told that this was not allowed, that it was
an all or nothing procedure. However, some of
the nurses noted that this was not the case at
all institutions. The ICU attending agrees.
Partial DNRs: Issues?

Can be very confusing to medical staff.

May be medically inappropriate.
i.e., “Do everything but intubate me”

Can lead to mistakes in care.

Slippery slope: At what point do we stop?
There are Appropriate Exceptions
I.e., The patient develops pneumonia and it is
expected that a short term intubation will
return the patient to baseline.
In this case, as it is consistent with the patient’s
wishes and medically appropriate, we should
intubate the patient.
Consider other, less invasive alternatives. I.e., a
“chemical” code prior to actually coding.
To Avoid Confusion

There needs to be clear communication between the
patient, care team, and other stake holders.

Typically, this will involve a condition which is expected
to be resolved quickly, not a condition which is part of
their underlying terminal illness.

We should discuss, in advance, what to do if the
treatment does not appear to be effective.

To avoid confusion with staff, it may help to post a sign
in the patient’s room indicating the unusual DNR status.
Best Option?

Don’t even call it a “Partial” DNR.

Simply recognize the sorts of procedures
which can occur even with a DNR order.

The bottom line is that we are here to
support patient goals within the context
of medical appropriateness, not a blind
adherence to a rule.
Case 4: Attempted Suicide
Your patient is a 64 y/o former counselor suffering from bi-polar
disorder and excessive clotting. Due to a state mix-up (not Iowa),
he has had difficulty getting medications.
Suffering from acute depression, he walked into a corn field and slit
his wrists.
Due to the untreated clotting disorder, he failed to bleed to death.
He was taken to the state psych ward and put on a suicide watch.
They left him his belt and only checked on him every 30 minutes.
He hung himself.
DNR status?
It is unsure to what extent, if any, the
patient will recover his cognitive abilities.
The family is considering a DNR.
Might a DNR be appropriate in this case?
If so, by what criteria?
Not Really Very Complicated

Complicating factors:
◦ Attempted suicide
◦ Patient is non-decisional

However, once the patient has been stabilized, the issue of the
attempted suicide is no longer a significant part of the ethical
discussion.

We make the decision on a DNR just as in any other case:
◦ Given the current medical indications,
◦ And the range of medically appropriate treatments
◦ what would the patient, if competent, want?
Case 5: Confusion of Authority
Your patient is a 78 y/o nursing home resident
in declining health admitted to the ICU
following surgery for a bowel obstruction. The
patient lacks decision making capacity.
Following an extended discussion with the
patient’s long term physician, the family asked
for a DNR. The patient’s primary care physician
agreed and entered the order. When the
patient’s surgeon discovered the order the next
day, he called the family, insisted strongly that
this was the wrong course of action, and
changed the order (citing family compliance.)
Nursing Concerns

When physicians disagree, to whom
should they listen?
◦ Both patients and other care givers can be
caught in the middle.

Some worried that the surgeon may have
pushed the family into agreement.
Concerns over Roles

What is an “Attending of Record”

What is a “Consultant?”
◦ Consult and Advise
◦ Consult and Treat

How might confusion about these roles harm:
◦ a patient/family?
◦ Professional Relationships?
Inspired a Change in Policy at the
Hospital in Question
It is now required that there be clear
communication and “hand offs,” in writing, for
who is the attending. Both the former
attending and the new attending must
acknowledge the hand off.
While other physicians may treat a patient, if
there is a conflict or disagreement, the attending
of record has the authority and responsibility
for the patient.
Case 6: Surgery on DNR Patients

You are caring for a 24 y/o patient with severe
MS, spinal bifida, paralysis of the lower limbs,
and multiple other medical problems. The
patient was brought from a nursing home to
address the bowel obstruction.

While not seeking to die, the patient is generally
decisional and has been a long term DNR. The
surgeon insists on removing the DNR before
surgery.
Why do surgeons usually insist on reversing a
DNR during and around the time of a
procedure?

Often, anesthesia effects can mimic or
even induce aspects of a code. The
surgeon wants to be able to address
these issues.
Do narcotics automatically render a patient nondecisional?

Even in the case of a true code, surgeon’s
don’t want a patient dying on their table.
Previous Practice
The DNR is reversed while on the
operating table and in the recovery room.
Once transferred to the ICU, the DNR is
put back into place.
Problems

This may not be consistent with patient wishes.
◦ The purpose of this surgery was comfort care, not
cure.
◦ If the patient suffers severe pulmonary edema and
needs to be intubated for several days to ameliorate
the situation, would the patient find this acceptable?
◦ If the patient suffers a major cardiac arrest while on
the operating table, would he/she want to go through
the pain and suffering of a code?
Problems

If the surgery runs long and the recovery
room is closed, the patient is taken
directly to the ICU.
◦ In this case, there is no clear line as to when
to reinstate the DNR.
What Actually Happened

The patient was taken directly to the ICU.

The DNR was not reinstated.

The patient coded and was resuscitated.

The patient died several days later.
Conclusions
Patients, either directly or via their surrogates,
have the right to continue a DNR order during
surgery.
Policies which either automatically suspend or
uphold a DNR order during surgery are
ethically suspect.
Requiring a patient to suspend a DNR order in
order to receive surgery is coercive and
ethically unacceptable.
Policy Should Include

Provisions for maintaining a DNR during
surgery.

Provisions for when a suspended DNR is to be
reinstated.

Requirements for communication and
documentation.

Provisions for dealing with unexpected
outcomes.