DNR Orders, Death Pronouncement and Notification

1. DNR Orders, Death Pronouncement and Notification Matthew S. Ellman, MD ICM, March, 2010

2. Content How to talk with patients about DNR orders How to do death pronouncement Death notification

3. Advance Directives Laws and forms vary 2 types: Health care power of attorney Living will Misconceptions Advanced Directive means �don�t treat� Named proxy means pt loses control Only old people need advance directives. � living will patient�s wishes re: medical tx. unable to communicate at end of life � living will patient�s wishes re: medical tx. unable to communicate at end of life

4. Advance Directives/DNR discussions: Hospital Admissions Start with goals of care and clinical scenario. �Perfunctory� vs. life-threatening condition Talior your approach to goals of care, clinical scenarioTalior your approach to goals of care, clinical scenario

5. �Perfunctory� Normalize �Hospital policy tells us that we should talk with all patients admitted about their wishes regarding health treatment preferences, including advance directives and cardiopulmonary resuscitation� Opportunity to elicit patient concerns/fears clarify misconceptions about condition, prognosis, and treatment options. Normalize: by indicating that hospital policy mandates that all patients be asked about advance directives when admitted. Normalize: by indicating that hospital policy mandates that all patients be asked about advance directives when admitted.

6. DNR orders in the Hospital Establish goals of care Do your homework! DNR discussion always take place in context of larger Goals of Care � that�s the key! Homework: Prior to discussions, MD should know data on outcomes and morbidity of CPR and patients underlying conditions DNR discussion always take place in context of larger Goals of Care � that�s the key! Homework: Prior to discussions, MD should know data on outcomes and morbidity of CPR and patients underlying conditions

7. CPR Outcomes Survival 20 minutes after CPR 44% Survival to discharge 17% VT/VF survival to d/c: 35% Pulseless or asystole survival to d/c:10% Pre-CPR 84% came from home; among survivors 51% returned home Neuro function: 86% level 1 remained that level and Functional performance: 25% decline Neuro function: 86% level 1 remained that level and Functional performance: 25% decline

8. �Talking points� for patients 17% or 1 in 6 who undergo CPR in the hospital may survive to discharge Specific co-morbidities reduce survival Surviving patients at risk for CPR related complications Conditions that reduce likelihood of survival: metastatic cancer, dementia, renal dialysis) Complications: permanent neurologic and functional impairment Conditions that reduce likelihood of survival: metastatic cancer, dementia, renal dialysis) Complications: permanent neurologic and functional impairment

9. DNR Discussion: 6 steps Establish setting What does patient understand? What does patient expect/goals of care? Discuss DNR order Respond to emotion Establish a plan

10. Establish setting Ensure comfort, privacy Ask who should be present Open generally: �I�d like to speak with you about possible health care decisions in the future�

11. What does patient understand? Understanding illness / prognosis for necessary for informed decision �What do you understand about your health situation?� Get the patient talking If understanding inaccurate-- now is time to review/correct Ask open �ended questionsAsk open �ended questions

12. What does the patient expect? Ask/listen: �What do you expect in the future?�, �What goals do you have for the time you have left?� If unrealistic, clarify Ask pt. to explain values underlying preferences. Clarify/confirm E.g.: �So what you�ve said is that you want us to do everything we can to fight but when the time comes, you want to die peacefully� Listen carefully to responses to look understand pts conceptions, hopes, fears, prioritiesListen carefully to responses to look understand pts conceptions, hopes, fears, priorities

13. Unreasonable requests for CPR Inaccurate information about CPR General public: CPR works 60-85% Patient and family hopes, fears and guilt Distrust of medical care system

14. Prognosis (median survival): Common cancer syndromes Malignant hypercalcemia: 8 weeks (except newly diagnosed myeloma or breast) Malignant pericardial effusion: 8 weeks Carcinomatous meningitis: 8-12 weeks Multiple brain mets.: 3-6 mos. with RT, 1-2 mos without. Malignant ascites, pleural effusion, bowel obstruction: < 6months.

15. Discuss DNR order Use language patient understands Don�t introduce CPR in mechanistic terms: ��intubation, CPR, press on your chest, tube down your throat, mechanical ventilation� Consider using word �die� or �if heart stops/unable to breath on your own�: clarifies that CPR is treatment tries to reverse death. Never say: �Do you want us to do everything?�

16. Discuss DNR order If appropriate, make clear recommendation against CPR. �We have agreed that the goals of care are to keep you comfortable�with this in mind I do not recommend the use of artificial or heroic means to keep you alive. If you agree, I will write an order in your chart that if you die, no attempt to resuscitate you will be made.� Appropriate means that both the MD and patient recognize death approaching, cpr unlikely to be effective or advisable treatment intervention and that the goal of care if comfort.Appropriate means that both the MD and patient recognize death approaching, cpr unlikely to be effective or advisable treatment intervention and that the goal of care if comfort.

17. DNR discussion If prognosis unclear and/or goals uncertain, ask about CPR �If you should die (or if your heart stops or you are unable to breath on your own) in spite of all our efforts, do you want us to use heroic measures to attempt to bring you back?� If asked to explain: Describe purpose, risks and benefits of CPR.

18. Respond to Emotion Strong emotions responses common, brief N.U.R.S. Silence may be best, reassuring touch, tissues. Name, understand, respect, supportName, understand, respect, support

19. Establish a plan Clarify orders for overall goals, not just DNR status Do not use DNR as proxy for other treatments �We will continue maximal medical therapy to meet you goals, however if you die, we won�t use CPR to bring you back� Or: �It sounds like we should move to a plan to maximize your comfort, so in addition to DNR order, I will ask our palliative care team to see you.�

20. Video Look for 6 steps What did MD do that did/did not work well? Think about what have you seen on the wards

21. Death Pronouncement More than actual declaration of death 3 key steps Examining patient to determine death Record proper documentation Notifying families Ref: www.mcw.edu/EPERC/FastFactsandConcepts, Heidenriech and Weissman, MD, 2000

22. �Please come to pronounce this patient� Preparation In the room Pronouncement Documentation medical record Notification � attending, relatives Phone: find out circumstances, ask if family present, basic info re: pt, don�t postpone Prepartion: speak with RN, findout if attending been called; family request autopsy?, determine if death reported for organ procurement, review chart for medical and family details. Room: may ask RN, chaplain to accompany, introduce yourself and relationship to patient, empathic statement, explain what you will do/invite to stay ask if family ahs questions, ask if you can contact someone -family , clergy; ask if there is anything you can do. Pronouncement: identfy pt, note ge.n appearance of body, ascertain no responsem listen for carotid pulse, look/listen for respirations, pupil postion/ absecne light reflex, record time assess. Done. Documentation: �called to pronounce�, chart PE findings, note time and date, ntoe if family / attending called; note if family accepts/declines autopsy/ document if ME notified.Phone: find out circumstances, ask if family present, basic info re: pt, don�t postpone Prepartion: speak with RN, findout if attending been called; family request autopsy?, determine if death reported for organ procurement, review chart for medical and family details. Room: may ask RN, chaplain to accompany, introduce yourself and relationship to patient, empathic statement, explain what you will do/invite to stay ask if family ahs questions, ask if you can contact someone -family , clergy; ask if there is anything you can do. Pronouncement: identfy pt, note ge.n appearance of body, ascertain no responsem listen for carotid pulse, look/listen for respirations, pupil postion/ absecne light reflex, record time assess. Done. Documentation: �called to pronounce�, chart PE findings, note time and date, ntoe if family / attending called; note if family accepts/declines autopsy/ document if ME notified.

23. Coroner�s/M.E. Reportable Case If patient in hospital <24 hours If death unexpected, unusual circumstances If death assoc w/trauma or a procedure Death during surgery or anesthesia Other - varies by state law

24. Pronouncement Video Clips Observe MD behavior Daughter�s reactions What you have seen in the hospital?

25. Informing Significant Others Family and friends look to MD for information, reassurance and direction Lasting impressions and memories Affects grief process, integration of loss This is why it matters Lasting memories about how they received word, how the MD acted Affects grieveing process for survivors This is why it matters Lasting memories about how they received word, how the MD acted Affects grieveing process for survivors

26. Overview of Notification Preparation Meeting with family/significant others Follow-up

27. Notification: preparation Confer with nursing, other staff Review record Examine patient Find private place to meet Involve other members of team Learn names of those you will talking to and relationship to deceased

28. Notification: Meeting with significant others Introduce yourself, identify others Invite to sit down with you Use eye contact & touch if appropriate Express condolence: �I�m sorry for your loss� Talk openly about death � use �died� or �dead� initially, then use words family uses Identify, respect culture & religion

29. Meeting with significant others If requested, explain cause of death in non-medical terms Offer assurance everything done to keep person comfortable Be prepared: range of emotion Offer opportunity to see deceased Prepare family

30. Seeing the deceased with significant others Model touching & talking to deceased Offer time alone, assure no rush Provide time to process before discussing autopsy/ organ donation Offer to return should questions arise Provide info for family to reach you

31. Follow-up Personalize sympathy card Consider attending wake, funeral Consider referral to bereavement support Encourage bereaved to see MD in 4-6 mos. Invite bereaved to meet with you re: questions/concerns; autopsy results

32. Organ donation request Determine eligibility ahead of time OPO & med. team should approach family together When? - after family realizes loved one will die OD cards are legally binding � tell don�t ask family Communication correlates of donation: Discussing specifics, incl. issues of cost, effects on funeral Family spending time with OPO staff Psychosocial support for grieving family

33. Autopsies: how families may benefit Discover inherited/familial/(infectious) conditions Uncover work-related disease Provide info. to settle insurance/death benefits Ease stress of unknown; finding dx/tx appropriate may provide comfort Medical knowledge gained may help others which may help ease pain of loss

34. Autopsies: common concerns Body treated w/respect & dignity; family wishes maintained all times Cost � usually none in teaching hospitals Should not delay funeral or affect viewing Some organs may be kept for detailed exam Most major religions leave decision to next- of-kin

35. Telephone Notification Can be challenging & stressful Dilemma: on the phone or ask to come in? Factors to consider: Death expected or not Relationship to and how well you know family Anticipated emotional reaction Whether person will be alone, level understanding Distance, transportation, time of day

36. Telephone Notification Prepare for the call Find quiet place to phone Call as soon as possible When delay likely, responsibility should be taken by covering MD all of above, know who you are calling, write down key information and review what you will sayall of above, know who you are calling, write down key information and review what you will say

37. Telephone Notification Identify yourself Identity of person reach Ask to speak with person closest, ideally: proxy or contact person Avoid responding until you have verification of identity No notification to minors

38. Telephone Notification: What to say Buckman: �giving bad news� Prepare What does patient know (What does patient want to know) Share the news (�warning shot�) Respond to emotion Plan

39. Phone notification: what to say If no prior relationship, ask what they know of condition: �What have MDs told you�?� Warning shot Clear direct language: �I�m sorry, ----- has just died.� (not �expired�, �passed away�, �didn�t make it�) Speak clearly & slowly Allow time for questions Be empathic

40. Phone notification: considerations Arrange to meet family Ask if you can contact anyone for them Do not leave news on voice mail If no contact in 1-2 hours � use social work If you feel uncomfortable, ask for help

41. Conclusions Observe role models, mentors Prepare Keep the dialogue patient-centered Respond to emotion Remember: patients will not forget Prepare know the facts of pateints clincial situation/ prognosis for advance directives/ DNR. For notification: know what happened with patient and whatvever you can about family, relationsip with patient Prepare know the facts of pateints clincial situation/ prognosis for advance directives/ DNR. For notification: know what happened with patient and whatvever you can about family, relationsip with patient