DNR Orders, Death Pronouncement and Notification Matthew S. Ellman, MD ICM, March, 2010.
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Transcript of DNR Orders, Death Pronouncement and Notification Matthew S. Ellman, MD ICM, March, 2010.
Content
1. How to talk with patients about DNR orders
2. How to do death pronouncement
3. Death notification
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.
Advance Directives/DNR discussions: Hospital Admissions
Start with goals of care and clinical scenario. “Perfunctory” vs. life-threatening condition
“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.
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
“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
DNR Discussion: 6 steps
1. Establish setting
2. What does patient understand?
3. What does patient expect/goals of care?
4. Discuss DNR order
5. Respond to emotion
6. Establish a plan
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”
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
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”
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
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.
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?”
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.”
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.
Respond to Emotion
Strong emotions responses common, brief N.U.R.S. Silence may be best, reassuring touch,
tissues.
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.”
Video
Look for 6 steps What did MD do that did/did not work well? Think about what have you seen on the
wards
Death Pronouncement
More than actual declaration of death 3 key steps
1. Examining patient to determine death
2. Record proper documentation
3. Notifying families
Ref: www.mcw.edu/EPERC/FastFactsandConcepts, Heidenriech and Weissman, MD, 2000
“Please come to pronounce this patient”
1. Preparation
2. In the room
3. Pronouncement
4. Documentation medical record
5. Notification – attending, relatives
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
Pronouncement Video Clips
Observe – MD behavior– Daughter’s reactions
What you have seen in the hospital?
Informing Significant Others
Family and friends look to MD for information, reassurance and direction
Lasting impressions and memories Affects grief process, integration of loss
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
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
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
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
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
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
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
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
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
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
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
Telephone Notification: What to say
Buckman: “giving bad news”
1. Prepare
2. What does patient know
3. (What does patient want to know)
4. Share the news (“warning shot”)
5. Respond to emotion
6. Plan
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
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