Transcript Slide Presentation - Curriculum for the Hospitalized Aging Medical

CHAMP
ADVANCE DIRECTIVES: The “DNR
Discussion”
Don Scott, MD, MHS
University of Chicago
Goals
1.
Recognize the Great Opportunity for improvement in
Conducting and Documenting Advance Directives
Discussions at the U of C
•
2.
Reinforce the Appreciation that Residents Learning
Advance-Directive-Discussion Skills is Critically
Important
•
3.
Opportunity for Commitment to Change and PBLI
Teaching a Strategy & then Observation or Modeling with
Feedback / De-Briefing is the Key
Increase strategies / resources for teaching residents /
students to improve their skills in advance directives
discussion AND DOCUMENTATION
Advance Directives
•REMEMBER, IT’S ADVANCE
DIRECTIVES NOT ADVANCED
DIRECTIVES
•Health-care Power of Attorney
•CPR  “Code Status” = The “DNR
Discussion”
•Dialysis
•Artificial Feeding
The U of C Data
Table 2: Documentation of Code Status across Sites
Site
1
2
3
4
5
6
n=5887
n=1244
n=4094
n=2661
n=2034
N=688
86%
43%
28%
88%
89%
72%
<0.00
01
Full code
4%
51.7%
58%
2.5%
4%
8.3%
<0.00
01
DNR/DNI
4.8%
3.9%
10.5%
4.25%
5.2%
10.9%
<0.00
01
No code
status
document
ed
Chi2
The U of C Data
Table 3:Documentation of Discussions across Sites
Site
Discussion
Documented
1
2
3
4
5
6
n=5887
n=1244
n=4094
n=2661
n=2034
N=688
3.1%
9.9%
24%
6.6%
5.7%
13.8
%
Chi2
<0.0001
Teaching Trigger 1:
Commitment to Change
• METHODS
– CAN USE PREVIOUS DATA ON SLIDES OR AS H/O’S
– CAN BE USED AS SIMPLE PRCTICE BASED LEARNING &
IMPROVEMENT PROJECT FOR MONTH ON WARDS
– CAN TEACH ANYTIME ANYWHERE
• TEACH NEED TO DO BETTER WITH # OF PATIENTS WE REACH
AND DOCUMENTING, ANYTIME CODE STATUS COMES UP
• COMMITING TO CHANGE
– WE HAVE A GREAT OPPORTUNITY FOR IMPROVEMENT
• INCREASE RECOGNITION OF THIS OPPORTUNITY FOR
IMPROVEMENT
How Well Do Residents Do
at Discussing Resuscitation?
A Typical Discussion ?
• OK, Mrs. Jones, there is just one
other thing I need to ask you
about your Mom, and that’s about
what you would want us to do if
her heart were to stop or she
needed to be on a breathing
machine. Would you want us to
use electrical shocks to her chest
or pound on her chest if her heart
stops or, you know, for instance,
put a breathing tube down her
throat if she can’t breath on her
own?
How do Residents Discuss
Resuscitation?
• JGIM; 1995, Tulsky et al. (n=45)
– Nature of the Procedure
–
–
–
–
–
Mech. Ventilation
Endotracheal Intubation
Cardioversion
Chest Compressions
Intensive Care
100%
84%
68%
55%
32%
– Outcomes
– Any Likelihood of Survival with CPR
– Numerical Estimate of Survival
– Patient’s Values or Goals
13%
O%
10%
How do Residents Discuss
Resuscitation?
• JGIM; 1995, Tulsky et al.
– Risks
• Prolonged ICU Stay
• Neurologic Sequelae
• Procedure-Related
Complications
– Alternatives
• Death
• Comfort Measures
– Recommendation
(“mild recommendation”
per authors)
3%
13%
16%
6%
32%
29%
Survival After Inpatient Cardiac Arrest
• Bedell, et al. prospectively studied 294 patients resuscitated at
Beth Israel Hospital 1981-1982
– 160 men, 134 women, age 18-101, mean 70
– 41% had AMI in the hospital, 73% had CHF, and 20% had previous
cardiac arrest
– 128 (44%) survived the arrest, and 41 (32% of survivors) lived until
discharge
• renal failure (3% of 75 patients survived, none on hemodialysis)
• cancer (7% of 59 survived, none with metastases)
• pneumonia (0% of 58 survived)
• none of the 42 patients with sepsis and none of the 16 patients
with CVA survived to discharge
• homebound before hospitalization (4% of 137 homebound
survived)
– Age was not a significant predictors
Survival After Inpatient Cardiac Arrest
• Taffet, et al. retrospectively studied 399 CPR efforts in 329
patients from 1984-1985 at the Houston VAMC
– 327 patients were men, age ranged 25-93, mean 62.6 years
– Older vs. younger cohort
• 24/77 (31%) successful CPR efforts in patients 70 or over, but none
survived to discharge
• 137/322 (43%) successful CPR efforts in patients younger than 70, and
22 (16%) survived to discharge
• mental function was more impaired in the older cohort after the
arrest
– Poor predictive factors
• diagnosis of cancer - 33/89 (37%) patients successfully resuscitated
and none survived to discharge
• diagnosis of sepsis - 33/73 patients resuscitated and one survived to
discharge
• age was a poor predictive factor, even when controlling for severity
of illness, except cancer and sepsis
•
•
•
•
location at the time of arrest
unwitnessed arrest
duration of resuscitation
number of medications administered during the arrest
The Hospitalized Elderly Longitudinal
Project (HELP)
• 1266 patients aged 80 or older at Beth Israel from 1/93-11/94
followed a mean of 711 days
• 505 patients died in the year following admission
• Strongest predictor was disease severity.
• Shortened survival for patients with functional impairment,
lower Glasgow coma score, and weight loss.
• Age only a moderate predictor.
• Geriatric conditions (hearing/vision loss,
confusion/disorientation, depression, bedridden/bed rest,
hip fracture, appetite change, social problems, frailty,
incontinence, falls) not associated with shortened survival.
• Depression and weight loss were not independent predictors.
How do Residents Discuss
Resuscitation?
• JGIM; 1995, Tulsky et al.
– Not Enough Info for Informed Choices
• Probabilities / Any Quantitation
– Little Attempt at Eliciting patients Values / Goals /
Concerns
– Physician Dominated Discussions
• Average Time = 10.5 minutes (2.5--36.1)
• Patients Spoke Avg = 2 mins 36 secs
– Residents Perceptions
• 90% Self-Assessed “Good Job”
• 77% Reported being “Comfortable”
– 33% Reported having Never been Observed
– 71% Observed 2 or Fewer Times
How do Residents Discuss
Resuscitation?
• Conclusion:
– “We recommend that communication about
end-of-life treatment decisions be treated as
a medical skill to be taught with the same
rigor as other clinical procedures.”
Prognosis with CPR
Prognosis: Expectations
• TV Shows = #1 Source of Info for older adults
regarding CPR
• Older adults overestimate CPR success by 
200%
• CPR Success on Television (NEJM):
– ER, Chicago Hope, Rescue 911
• 75% survived Immediate Arrest
• 67% appeared to survive to D/C
• 83% = Young Adults
• Outcomes = ALWAYS either Full Recovery or Death
PROGNOSIS: Probability of Surviving
to Discharge after CPR
• General Med Service All Patients: 7-14%
• Most Commonly Used, All-Comers 10%
Estimate
• “Chronically Ill” Older Adults
<5%
• Primary Cardiac Disease in
30-40%
Younger Adult (< 55)
PROGNOSIS: Probability of Surviving
to Discharge after CPR
• Predictors of Especially Poor Prognosis for
Survival to D/C after CPR
–
–
–
–
–
Malignancy, esp metastatic
Chronic Renal Failure (SCr > 1.7)
Sepsis or Pneumonia as admitting Dx
Poor Functional Status—”Frailty”
Age > 70 ???
TEACHING TRIGGER 2: Prognosis
• WHEN GIVING FEEDBACK, OR
PLANNING FOR OR WHEN
DEBRIEFING AFTER AD DISCUSSION
– Ask about learner’s knowledge of prognosis
– Emphasize importance of offering general
prognostic information, regarding CPR, to
patients and families
– Emphasize importance of talking about
Complications of CPR and Alternatives
Discussing & Documenting
Advance Directives
Discussing & Documenting Advance
Directives
• THE IDEAL WORLD
– SHOULD HAPPEN WITH EVERYONE
– SHOULD BE:
• An Evolving Discussion
• Including and Evolving Exploration of Patient’s Values
– What Makes Life worth Living?
• Not Done on the Fly…as much time as needed
• THE WARD WORLD
– Those in Whom We Feel Resuscitation is Futile /
Harmful
• THE VERY SICK & THE VERY OLD
– Often in time-pressured setting and done on the fly
Teaching Trigger 3: AD’s &
Transitions of Care
• Post-Call / Short-Call Presentation
– 1st Time “Code Status” is Mentioned
• HAS THE PATIENT’S PRIMARY CARE DOCTOR
BEEN CONTACTED?  Transitions of Care
– ADVANCE DIRECTIVES MAY ALREADY BE WELL
ESTABLISHED
– IF NOT, PMD STILL MAY HAVE IMPORTANT
INSIGHTS—PATIENT’S VALUES AND FAMILY
DYNAMICS
• OPPORTUNITY TO REMIND RESIDENTS TO
WORK ON ESTABLISHING AD’S WITH ALL OF
THEIR PATIENTS IN CLINIC
First Steps
1. Are there advanced directives in place?
2. Do you think CPR is appropriate?
3. Is patient decisional?
•Is there a guardian?
•Is there a named surrogate and
documentation?
4. Know who patient wants to participate
5. Do other team members want to
participate?
Conducting the DNR Discussion
with a Seriously Ill Patient
1.
Define the Purpose of the Discussion (if a planned meeting)
I would like to talk with you about possible health care decisions in the
future.
2.
Ask what Patient / Family Understands about Current
Condition
What is your understanding of your current health situation?
3.
Review Current Condition / Prognosis & Review Treatment
Plan (what has been done / tried)
4.
Inquire about Patient’s Values or Goals
– “What are your goals for the time you have left; what is important
to you? “
– “How would you define an acceptable (or good) quality of life?”
– “What sorts of things make ‘life worth living’ to you?”
Conducting the DNR Discussion
with a Seriously Ill Patient
5.
6.
7.
Introduce and Define CPR (if needed)
Discuss Benefits / Burdens of CPR
–
INCLUDE A PROGNOSIS STATEMENT SPECIFIC TO
CPR IN THIS CASE
–
Include information regarding possible complications
Stress Symptom Relief, No Matter the Decision
–
8.
Palliative Measures
Reinforce that DNR does not mean “do not treat”
–
Will continue to receive all the types of care you are
receiving now
Conducting the DNR Discussion
with a Seriously Ill Patient
10. If Patient lacks Capacity and Family is Deciding
–
Stress the Patient’s Perspective
• What Family Believes Patient Would Want
?
• What Patient Most Valued in Their Life ?
• Did Patient Ever Say Anything about this?
Teaching Trigger 4 : Scheduled or
Spontaneous Discussion
• Key: Observation WITH Feedback
– With Specific Teaching Points Before and After
– Should not be only “See One, Do One”
• Key: Modeling with Debriefing
– You or Resident
– Afraid of doing a Poor Job?
• Don’t Miss Opportunities: “I’m too old for all of
that.”
– Observe  SPECIFIC Feedback
– Use Sit-Down Debriefing for Scheduled Discussion
– You take advantage of Moment when It Arises 
Modeling the Discussion
Conducting the DNR Discussion
Statements to Avoid
• Do you want us to do everything?
• It doesn’t look very good.
• What should we do if your (or your mother’s) heart
stops?
• If we do CPR and break your ribs and you need to be on
a breathing machine, do you want us to do that?
• We will not do _________ (invasive or aggressive or
extraordinary) measures, if that’s OK with you.
• Avoid the term, “futility”
FINISHING the DNR Discussion
• Review DNR Decision with staff
• Write DNR order
Documentation is Crucial
• MUST WRITE A BRIEF PROGRESS NOTE
– YOUR JOB IS NOT DONE UNTIL YOU DO
SO
– IF IT IS NOT DOCUMENTED, IT DID NOT
HAPPEN
Documenting the DNR Discussion
• Need not be Elaborate
1. Document Who Present
2. Document Capacity
– Who is making the Decisions?
3. Document what was decided and
why
A Sample Note
An advance directives discussion was held with
Mr. Smith, with his wife and daughter also
participating. Mr. Smith has decision making
capacity for this decision. Given Mr. Smith’s
advanced heart and lung disease, his values for what
constitutes a meaningful life for him, and his very
poor prognosis if CPR were necessary, we have
reached a joint decision that Mr. Smith would not
wish to be resuscitated.
TEACHING TRIGGER 5
• REVIEW AND / OR TEACH HOW TO
WRITE A SHORT BUT FULL NOTE
• CHART REVIEW / CHART AUDIT
• PBLI OPPORTUNITY
Summary
• Teaching of Advance Directives Communication
Skill is a critically important skill—as (?more)
important than central lines
• Commit to Change: We do a Poor Job here at
Documenting Advance Directive Discussions
• Need to teach discussion CPR-Prognosis Issues
• Need a plan for doing, observing and giving
feedback
• Important to teach how to efficiently document
Resources
• End of Life/Palliative Education Resource
Center
– http://www.eperc.mcw.edu
• The American Academy on the Physician
and Patient
– http://www.physicianpatient.org/
Words & Phrases: Examples
• Beginning the Discussion
– I know this is a very difficult time for you and your
family, and it may be a frightening time for you as
well. I want you and your family to know that I am
here to help you, and I will do all that I can to help
you deal with this illness and the tough decisions we
need to make together (and with Dr. _______ [PMD]).
– I would like to take this time for us to discuss an
important topic--I would like to talk about what we
should do if you became even sicker or were to die
Adapted from: Weisman, MD. Communication Phrases
Near the End of Life-Pocket Card, EPERC
Words & Phrases: Examples
• Beginning the Discussion:
– As your doctor, I want to make sure we are
always doing the things that might help you,
and that we never do anything that can’t help
you , or that you would not want us to do.
Let me begin by asking what your
understanding is of your current illness and
what the future holds?
Adapted from: Weisman, MD. Communication Phrases Near
the End of Life-Pocket Card, EPERC
Words & Phrases: Examples
• Clarifying a Poor / Grave Prognosis
– “Do you have any sense of how much time is left and
would you like to talk about that?”
– I don’t intend to be unkind or harsh when I tell you
this, but I want to be sure I am being as clear and
straightforward as possible about your condition. I
believe that despite everyone’s best efforts, and yours,
that your disease is now very advanced and that you’re
in the last stage of your life. What are your thoughts?
(or just wait in silence for reaction)
– May use terms like “hours/days”,
“days/weeks”, “weeks/months”
Adapted from: Weisman, MD. Communication
Phrases Near the End of Life-Pocket Card, EPERC
Words & Phrases: Examples
• When CPR is Indicated or there is Substantial
Uncertainty
– OK, so we’ve discussed you current situation and what
you value most at this stage of your life. Have you
given any thought to how you would like to be cared
for at the time of death? Sometimes when people die, or
are near death, life support measure are used to try and
bring them back, alternatively, we could focus solely on
keeping you comfortable. How do you feel about this?”
Adapted from: Weisman, MD. Communication
Phrases Near the End of Life-Pocket Card, EPERC
Words & Phrases: Examples
• When CPR is Not Indicated
– “OK, so we’ve talked a bit about you’re current condition and
what’s most important to you at this stage of your life. With this
in mind, I believe that if you were to die that performing CPR will
have a great chance of causing suffering and harm and offer almost
no hope of meaningful benefit, of helping you. I do not recommend
the use of artificial or heroic means to keep you alive, such as chest
compressions, electrical shocks to your chest or placing a breathing
tube and connecting you to a breathing machine. If you agree with
this, I will write an order in the chart that if you are to die, that
these things will not be done to you. I want to emphasize that this
does not mean that we will not continue to care for you in all the
other ways we have been doing. Is this OK?
Adapted from: Weisman, MD. Communication Phrases Near the End of Life-Pocket Card, EPERC