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Content. How to talk with patients about DNR ordersHow to do death pronouncementDeath notification. Advance Directives. Laws and forms vary2 types: Health care power of attorneyLiving will Misconceptions Advanced Directive means
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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 dont treat
Named proxy means pt loses control
Only old people need advance directives.
living will patients wishes re: medical tx. unable to communicate at end of life
living will patients 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 thats 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 thats 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: Id 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 youve 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
Dont 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 comfortablewith 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 wont 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, dont 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, dont 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. Coroners/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
Daughters 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: Im 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 dont 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: Im sorry, ----- has just died. (not expired, passed away, didnt 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