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CHAMP ADVANCE DIRECTIVES: The “DNR Discussion”. Don Scott, MD, MHS University of Chicago. Goals. Recognize the Great Opportunity for improvement in Conducting and Documenting Advance Directives Discussions at the U of C Opportunity for Commitment to Change and PBLI

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Champ advance directives the dnr discussion l.jpg

CHAMPADVANCE DIRECTIVES: The “DNR Discussion”

Don Scott, MD, MHS

University of Chicago


Goals l.jpg
Goals

  • Recognize the Great Opportunity for improvement in Conducting and Documenting Advance Directives Discussions at the U of C

    • Opportunity for Commitment to Change and PBLI

  • Reinforce the Appreciation that Residents Learning Advance-Directive-Discussion Skills is Critically Important

    • 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 l.jpg
    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 l.jpg

    Site

    1

    2

    3

    4

    5

    6

    Chi2

    n=5887

    n=1244

    n=4094

    n=2661

    n=2034

    N=688

    No code status

    documented

    86%

    43%

    28%

    88%

    89%

    72%

    <0.0001

    Full code

    4%

    51.7%

    58%

    2.5%

    4%

    8.3%

    <0.0001

    DNR/DNI

    4.8%

    3.9%

    10.5%

    4.25%

    5.2%

    10.9%

    <0.0001

    The U of C Data

    Table 2: Documentation of Code Status across Sites


    The u of c data5 l.jpg

    Site

    1

    2

    3

    4

    5

    6

    Chi2

    n=5887

    n=1244

    n=4094

    n=2661

    n=2034

    N=688

    Discussion

    Documented

    3.1%

    9.9%

    24%

    6.6%

    5.7%

    13.8%

    <0.0001

    The U of C Data

    Table 3:Documentation of Discussions across Sites


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    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


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    How Well Do Residents Doat Discussing Resuscitation?


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    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?


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    How do Residents Discuss Resuscitation?

    • JGIM; 1995, Tulsky et al. (n=45)

      • Nature of the Procedure

        • Mech. Ventilation 100%

        • Endotracheal Intubation 84%

        • Cardioversion 68%

        • Chest Compressions 55%

        • Intensive Care 32%

    • Outcomes

      • Any Likelihood of Survival with CPR 13%

      • Numerical Estimate of Survival O%

  • Patient’s Values or Goals 10%


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    How do Residents Discuss Resuscitation?

    • JGIM; 1995, Tulsky et al.

      • Risks

        • Prolonged ICU Stay 3%

        • Neurologic Sequelae 13%

        • Procedure-Related 16%

          Complications

      • Alternatives

        • Death 6%

        • Comfort Measures 32%

      • Recommendation29%

        (“mild recommendation”

        per authors)


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    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


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    SurvivalAfter 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


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    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.


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    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


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    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.”



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    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 l.jpg
    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)


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    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 l.jpg
    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 l.jpg
    Discussing & Documenting Advance Directives


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    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 l.jpg
    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 l.jpg
    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 l.jpg
    Conducting the DNR Discussion with a Seriously Ill Patient

    • 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.

    • Ask what Patient / Family Understands about Current Condition

      What is your understanding of your current health situation?

    • Review Current Condition / Prognosis & Review Treatment Plan (what has been done / tried)

    • 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 patient26 l.jpg
    Conducting the DNR Discussion with a Seriously Ill Patient

    • 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

      • 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 patient27 l.jpg
    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 l.jpg
    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 l.jpg
    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”


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    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 l.jpg
    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 l.jpg
    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 l.jpg
    TEACHING TRIGGER 5

    • REVIEW AND / OR TEACH HOW TO WRITE A SHORT BUT FULL NOTE

    • CHART REVIEW / CHART AUDIT

    • PBLI OPPORTUNITY


    Summary l.jpg
    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


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    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 l.jpg
    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 sickeror were to die

    Adapted from: Weisman, MD. Communication Phrases Near the End of Life-Pocket Card, EPERC


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    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


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    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


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    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


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    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


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