Health Assessment and Measurement: Adult/Geriatric Variations

1. Improving Patient & Provider Communication Related to Code Status & Goals of Care in the Geriatric Population Health Assessment and Measurement: Adult/Geriatric Variations Angela Frey, Kathy Mooney, Tania Randell, & Allison Schuler

2. Objectives • Explore barriers to patient and provider communication regarding definition of code status and goals of care. • Identify best practices for optimal communication between patient and provider. • Provide resources for patients and providers to assist in this communication. Recommended Readings Timing of do-not-resuscitate orders for hospitalized older adults who require a surrogate decision-maker. How Misconceptions Among Elderly Patients Regarding Survival Outcomes of Inpatient Cardiopulmonary Resuscitation Affect Do-Not-Resuscitate Orders

3. Background • Discussions of code status can be difficult to initiate for both patients and the healthcare team. • Patients and family members do not have a clear understanding of DNR and require education before making an informed decision. • Studies have shown that patient’s code status preferences do not always match their code status orders • Miscommunication can also lead to angst for family members surrounding the death of their loved one. (Kaldjian, Erekson, Haberle, Shinkunas, Cannon, & Forman-Hoffman, 2008).

4. Background Continued • Historically patients and caregivers have had miscommunication about end of life wishes and goals. This can lead to medical care that does meet their wishes. • Under the Patient Self Determination Act, patients are entitled to the right to facilitate their own health care decisions, the right to accept or refuse medical treatment and the right to make an advanced health care directive. (Murphy & Price, 2007).

5. Barriers • Lack of knowledge • Medical jargon and health illiteracy • Studies have shown that patients overestimate the probability of surviving cardiac arrest highlighting the importance of education before decision making • Patients goals of care do not correspond with DNR status. • Healthcare providers • Lack of training in having DNR discussions • Fear that patients will feel abandoned • Time constraints • Lack of understanding of patient wishes or goals of care • Disagreement among health care providers about role in decision making • Communication • Language barriers • Patients who are hard of hearing • Patients with dementia or delirium • Patients who are unable to communicate their wishes during acute health crisis • Discrepancies among patients, families, and providers as to who should have final say in DNR orders (Adams & Snedden, 2006).

6. Best Practices • Address the topic of DNR early • Use teach-back-method of communication to ensure complete understanding of discussions • Provide education for health care providers on how to best communicate DNR discussions with geriatric patients • Health care providers should be aware of current evidence of CPR outcomes and be able to share this information with patients (Kaldjian, Erekson, Haberle, Shinkunas, Cannon, & Forman-Hoffman, 2008).

7. Best Practices Continued • Use a collaborative approach • DNR decision making must be supported by ethical theory when dealing with surrogates for the geriatric population. • Advanced directive planning must focus on preparing patients and families for making the best decision in the moment. This can be done by choosing an appropriate surrogate, clarifying goals, and articulating the patient’s values. • Designate a unit expert or facilitator to foster optimal communication during DNR/goals of care discussions. (Levin, Li, Weiner, Lewis, Bartell, Piercy, et al, 2008). (Adams & Snedden, 2006).

8. Resources for Patients & Providers • Maryland MOLST guide click here. More specific information is on the Maryland MOLST guide for patients and caregivers web site click here. • American Hospice Foundation offers advanced directive/living will information click here ,as well as information on how caregivers can work with healthcare providers during a serious illness of a loved one click here. • NIH offers information on communicating with caregivers and includes cultural differences as well as improving communication using family meetings click here.

9. Resources for Patients & Providers • Advanced Directives/Living will information web site click here . • Educational materials for healthcare workers to facilitate DNR discussions with patients click here . • Caring Connections offers information and support for those planning their advanced directive, caring for a sick loved one, persons whom may be ill themselves or are grieving the loss of a loved one click here. Caring Connections offers numerous brochures including legal information regarding advanced directives/living wills as well as a section on planning ahead which includes a brochure on how to begin end of life conversations before one becomes seriously ill click here.

10. References • Adams, D. H., & Snedden, D. P. (2006, July). How misconceptions among elderly patients regarding survival outcomes of inpatient cardiopulmonary resuscitation affect do-not-resuscitate orders. The Journal of the American Osteopathic Association, 106(7), 402-404. • Kaldjian, L. C., & Broderick, A. (2011, January). Developing a policy for do not resuscitate orders within a framework of goals of care. The Joint Commission Journal of Quality and Patient Safety, 37(1), 11-20. • Kaldjian, L. C., Erekson, Z. D., Haberle, T. H., Curtis, A. E., Shinkunas, L. A., Cannon, K. T. et al. (2009). Code status discussions and goals of care among hospitalized adults. Journal of Medical Ethics, 35, 338-342. • Levin, T. T., Li, Y., Weiner, J. S., Lewis, F., Bartell, A., Piercy, J. et al. (2008). How do-not-resuscitate orders are utilized in cancer patients: Timing relative to death and communication-training implications. Palliative and Supportive Care, 6, 341-348. • Murphy, P., & Price, D. (2007, March). How to avoid DNR miscommunications. Nursing Management, 38(3), 17, 20. • Resnick, L., Cowart, M. E., & Kubrin, A. (1998). Perceptions of do-not-resuscitate orders. Social Work Health Care, 26(4), 1-24. • Robinson, C., Kolesar, S., Boyko, M., Berkowitz, J., Calam, B., & Collins, M. (2012, April). Awareness of do-not- resuscitate orders, what do patients know and want? Canadian Family Physician, 58, 229-233. • Sudore, R. L., & Fried, T. R. (2010, August). Redefining the "planning" in advanced care planning: Preparing for end-of-life decision making. Annuals of Internal Medicine, 153(4), 256-261. • Sulmasy, D. P., He, M. K., McAuley, R., & Ury, W. A. (2008). Beliefs and attitudes of nurses and physicians about do not resuscitate orders and who should speak to patients and family about them. Critical Care Medicine, 36(6), 1817-1822. • Sulmasy, D. P., Sood, J. R., & Ury, W. A. (2008). Physicians' confidence in discussing do not resuscitate orders with patients and surrogates. Journal of Medical Ethics, 34, 96-101. • Torke, A. M., Sachs, G. A., Helft, P. R., Petronio, S., Purnell, C., Hui, S. et al. (2011, July). Timing of do-not-resuscitate orders for hospitalized older adults who require a surrogate decision-maker. The American Geriatric Society, 59(7), 1326-1331. • Yang, G. M., Kwee, A. K., & Krishna, L. (2012, April 1). Should patients and family be involved in "do not resusciate" decisions? views of oncology and palliative care doctors and nurses. Indian Journal of Palliative Care, 18(1), 52- 58.