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Advance Directives
 This
presentation is based on the July 2003
AHRQ WebM&M Spotlight Case
 See the full article at http://webmm.ahrq.gov
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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
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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.
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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.
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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.
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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.
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Common Features of
Code Status Discussions
 Use

“Would you want your life prolonged?”
 Use

of vague language
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.
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Common Features of
Code Status Discussions
 Domination

Physicians speak nearly three-fourths of the time
 Use

of discussion by physician
of medical jargon
Without confirming patients understanding
Tulsky JA, et al. J Gen Intern Med. 1995;10:436-442.
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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.
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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.
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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.
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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.
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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.
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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.”
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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.
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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
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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