CHAMP ADVANCE DIRECTIVES - University of Chicago

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Nov 16, 2013 (3 years and 9 months ago)

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CHAMP

ADVANCE DIRECTIVES: The “DNR
Discussion”

Don Scott, MD, MHS

University of Chicago

Goals

1.
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

2.
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

3.
Increase strategies / resources for teaching residents /
students to improve their skills in advance directives
discussion AND DOCUMENTATION


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


Table 2: Documentation of Code Status across Sites


Site


1


2


3


4


5


6


Chi2





n=5887


n=1244


n=4094


n=2661


n=2034


N=688





No
code
status

document
ed


86%


43%


28%


88%


89%


72%


<0.00
01


Full code


4%


51.7%


58%


2.5%


4%


8.3%


<0.00
01


DNR/DNI


4.8%


3.9%


10.5%


4.25%


5.2%


10.9%


<0.00
01


The U of C Data

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


Table 3:Documentation of Discussions across Sites


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


How Well Do Residents Do

at Discussing Resuscitation?

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?

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%


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%


Recommendation


29%


(“mild recommendation”


per authors)


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



Survival

After 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



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.




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

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.”

Prognosis with CPR


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


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)





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


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


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


Post
-
Call / Short
-
Call Presentation


1
st

Time “Code Status” is Mentioned


HAS THE PATIENT’S PRIMARY CARE DOCTOR
BEEN CONTACTED
?


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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

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


1.
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.

2.
Ask what Patient / Family Understands about Current
Condition


What is your understanding of your current health situation?

3.
Review Current Condition / Prognosis & Review Treatment
Plan
(what has been done / tried)

4.
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 Patient

5.
Introduce and Define CPR (if needed)

6.
Discuss Benefits / Burdens of CPR


INCLUDE A PROGNOSIS STATEMENT SPECIFIC TO
CPR IN THIS CASE


Include information regarding possible complications

7.
Stress Symptom Relief, No Matter the Decision


Palliative Measures

8.
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 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


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


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䙥敤F慣


Use Sit
-
Down Debriefing for Scheduled Discussion


You take advantage of Moment when It Arises


䵯摥汩湧⁴桥⁄M獣畳獩潮

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”


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


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




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


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



CHART REVIEW / CHART AUDIT



PBLI OPPORTUNITY


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

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


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 sicker

or were to die

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


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


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


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


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