The USA Today had a feature article this week highlighting the careful use of words to construct the order to no longer initiate CPR. (Don't miss the 170+ comments, very enlightening about how th epublic feels) The author focuses on the growth of the "Allow Natural Death" phrase as a compassionate alternative to "Do Not Resuscitate."
The prevailing medical order in the United States is "Do Not Resuscitate" and is usually abbreviated as DNR. It has been codified into law and etched in health care organization policies. The very direct nature of the command defines its usefulness. Do. Not. Resuscitate. Should be pretty clear with the precision and simplicity of the words. Some doctors would argue there are different aspects of resuscitation and a buffet approach could be approached. Chemical Code Only, Resuscitate but Do Not Intubate, Shock Only, etc. Specific changes to DNR orders should be written very clearly so as not to cause more confusion in an emergency, which is why I favor not making these changes unless absolutely necessary which is uncommon.
I first noticed the Allow Natural Death order on transfer paperwork for a hospice patient a few years ago. Never heard of it before then. What did it mean exactly as a medical order? Is morphine natural? Are antibiotics natural? Does this patient consider artificial hydration or nutrition as natural (To some that is a contradiction but others would disagree)? It left too many questions for me to consider it a helpful or accurate medical order.
I don't think I would write an order: "Make this patient's hemoglobin normal." I would need to write to transfuse a specific amount of blood and maybe specify to initiate the action when the patients hemoglobin was below a specified threshold. Ambiguity in medical orders is a situation ripe for error. For this reason medical orders regarding such momentous life and death decisions should not be ambiguous. Exactly the same reason to avoid orders such as DNR-A, DNR-B, DNR-C.
The article itself covers the pros and cons of each order very well. The proponents of Allow Natural Death orders believe it to be more compassionate and better accepted by patients and families. Anecdotal evidence to be sure but not to be ignored. But maybe the source of compassion does not come in the writing of an order but in the communication of the medical plan once the goals have been delineated. Efforts should be made to explain the medical care as defined by the goals of care set in a shared decision making situation. That would be the ideal situation.
To highlight how intrinsically the goals of care and the code status (DNR v CPR) are tied, I have begun writing the following orders as a set for any palliative care consultation and at any change in goals or code status.
Goals: Curative, Restorative, Comfort (occasionally I will use a combination of two if appropriate)
Code Status: Full Code, Do Not Attempt Resuscitation
Do any of you use the "Goals:" as a medical order or as a special section in your plan? I began doing this when doctors started jumping ship once a palliative care consult was called. This way I could alleviate their concerns the patient was still focusing on curative goals and we were following along for support. The DNR-A, B, C system seems to address this as well, but the abbreviation does not make sense, and would it really throw someone off schedule to write a few more letters for something so important?
Also, abbreviating DNR as a medical order is a shortcut that does not reflect the gravity of the decision so I have recently decided to write it out every time. That is another reason why Allow Natural Death does not work as an abbreviation. Imagine the following order in a chicken scratch illegible black pen (which I have seen before)
D/C abx
AND
xfer to medical floor
Once I saw that I quickly clarified a new order.
What are your pet peeves/concerns/thoughts about DNR orders?
I am just glad that no one mentioned DNR Commies in this article!
14 comments:
We are struggling mightily with the issue of goals of care vs. DNR "status" in my instution. Inappropriate (at times) inferences are drawn from the presence or absence of a DNR order. For example, I had a very difficult time getting a venting gastrostomy placed in a DNR patient because she was DNR ("we don't do procedures on these patients"). It happens on the other end of the spectrum as well, this is part of why patients, particularly those who are underfunded, are suspicious of DNR. We are working toward separating our processes--so that the code status orders pertain only to what happens at the moment of death, and there is a separate/ongoing process of goal setting to work out the rest.
The DNR issue is such an important one that patients and families really don't understand. It's so difficult to explain that we as physicians often are unable to provide an accurate prognosis when someone has a terminal illness complicated by a multitude of chronic and acute medical conditions.
I try to teach that delineating goals is necessary prelude to discussing interventions - in our institution, the main decision points are, if health status changes: 1. full court press to prolong life/restore function, incl. intubation & ICU transfer -may or may not incl. CPR for arrest, 2. "ward-based" interventions to attempt to prolong life/restore function, e.g. investigations, IV's, Abx, etc. - almost always no CPR, or 3. no interventions aimed at reversing decline or prolonging life ... I'd argue that comfort is a goal at each step. The problem with separating "comfort" as a separate category - may imply that sx control is less important in 1. & 2. Chest 2007;132 had a good point-counterpoint on CPR, one author arguing against autonomy/choice in pts with predictably poor outcomes. Paul McIntyre
Leigh,
I too had the same struggles with health care staff (doc, nurses, PT, OT, Speech, etc, etc) assuming a palliative care consult team following a patient meant the goals were comfort only. "I don't see why they need you guys..." was/is a common refrain. We primarily educate by the ones on this, and try to make people realize that we also advocate for curative/restorative measures when appropriate with the patients goals. After a DNAR is established I sometimes am on the defensive trying to make sure the patient still gets other medical opportunities if it matches their goals.
Dr. Kim,
Agreed that DNAR orders and discussions are often misunderstood by families and patients which is why a lot of time in family conferences is spent exploring this issue, usually after goals of care are already established. Prognostication has a lot to do with the uncertainty of docs and patients to commit to DNAR since we have few helpful prognostication tools and physician skill at prognostication could be easily called into question. Especially if there is a disagreement among docs!
Paul,
Excellent point. Goals of care first, Outline of appropriate therapies second. This is at the heart of most of our consults. And is an excellent teaching point. When it is just asked "Do you want us to do everything?" that is not a goals of care discussion. Yet many docs and families think that is all it takes. The question is loaded/biased and glosses over so many nuances and values of the patient and medical facts.
I like the 'ward-based interventions' phrase. Will ahve to try that sometime.
I would agree that comfort should be an option regardless of goals, and so to be more exact maybe 'Goals: Comfort Only' would be more precise. The fact that palliative care is following would mean that comfort is always one of the goals unless the patient explicitly sacrifices a degree of symptom control because of other reasons. Those reasons of course have to be explored and misinformation corrected.
Do you have a one or two word phrase instead of comfort that sums up #3?
Leaving CPR decisions solely to families and patients is not the best case scenario for shared decision making. Making strong recommendations based on medical professionalism and nonmaleficence may trump autonomy at times, but usually in the US at this would at least require medical consensus (not always possible) or an Ethics consult.
Forgive the intrusion, Christian, from someone without a formal medical background, but I have a question: What, exactly, in medical terms, does "curative" mean?
I'm asking for a variety of reasons, not necessarily connected to the following observation: My mother had chronic anemia, so I was astonished to notice the "order": "Make this patient's hemoglobin normal." Even with a DNR, there was the tacit and overt assumption, when she was on hospice, that if my mother's hemoglobin dropped precipitously but she continued to appear to be "okay" otherwise, that she would be transfused to a level (usually in the high nines; I know, that's low but it worked for her, especially since, from that point on, with her sturdy iron supplements, she'd recover into the 10s and 11s) at which she "perked up". As it turned out, her hemoglobin remained steady and high enough right up to her death. In addition, of course, hospice wasn't addressing her anemia, except indirectly (as possibly being caused by her cancer, but, then, there were other possible causes, as well). And, from a panoramic perspective, although her anemia was often addressed before she went into hospice, twice with blood transfusions, it was never "cured". So, you know, according to medical terminology, what does "curative" mean?
Thanks, Christian. I'll appreciate any clarification you can give me.
to the last poster: i think what is typically meant by palliative care folks when they say "curative" is disease-modifying treatment, or treatment that is intended and capable of altering the underlying disease status. for example there are many reasons why someone can be anemic, and some conditions can be definitively treated (bleeding, iron-deficiency) while others have a more indolent and treatment refractory course (think myelodysplasia or hematologic malignancies) that we really have no effective treatments for. giving all the blood transfusions in the world in the latter case will really have no meaningful impact on the disease.
christian, i'm not sure how a typical hospital ward nurse (who probably has very little education on palliative care) would be expected to interpret an order that says "goal comfort only"
I know that in the hospital where I work, I would immediately get a call from the nurse, nurse supervisor and patient care director asking me to explain what such an order is supposed to mean, and what the nurse is supposed to do exactly. So I would have reservations about writing such an order, and I would need to first speak to the nurse and get specific about the type of treatment I had in mind.
I do wholeheartedly agree with your contentions that it is a fallacy that just because palliative care is following a patient, the assumption is that the patient is imminently dying and/or under hospice, and therefore everybody else should sign off; unfortunately at my institution we see this often as well, not just from other docs but also from ancillary services (speech therapy, PT/OT) who actually could have a very positive impact on patients who are struggling with serious illness but are not exactly comfort care only / end-of-life.
I also overwhelmingly agree that we cannot expect patients and families to make decisions on code status solely on their own; that there must be some guidance from physicians about what care is appropriate and may be offered; and that we cannot ethically offer treatment that provides no benefit even if families demand it. there is something to be said for old-school white coat paternalism in medicine, and unfortunately it seems to me we have lost alot of this authority in this age of patient choice.
Gail Rae,
The anon poster after you had it about right by what is meant by 'curative' in goals of care. Curative meaning disease modifying and generally more aggressive care.
You make an excellent point about the nature of chronic disease and how it might be 'cured/modified' to the point it may not be an issue anymore. And that the treatment target is set dependent on what the patient/family goals are (hopefully).
The point you make about the hemoglobin is one that often comes up in palliative care or hospice situations. Do we treat the number or the patient in front of us? Much of medicine is reflexively taught to treat the number and that is a good thing for the most part because it makes sure that some early signs of decline/disease might be averted. But when it becomes so routine that treating the number without referring to the goals of care for the patient, then you risk clinical inertia bowling over the patient for the sake of improving the numbers.
Anon,
Excellent point about interpreation of the "goals" as written in the orders. I have started writing "goals of care: x" in the orders b/c what was written in the note (with legible writing) was not always shall I say 'processed' by many other clinicians. In addition to writing "goals of care: x" in the orders, I also write clarifying orders for special situations, such as "d/c antibiotics" or "continue bipap, and titrate to patients comfort, not o2 sat" etc. My progress note from the same date also gives more information in how that decision was made and the foundation for the decision.
And lastly, the team and myself make strong efforts to communicate with the covering nurse to explain any nuances and give them some time to ask questions. I think this part is key to an effective consultation.
Thanks all for the comments...FUN! STUFF!!
Thank you, Anonymous and Christian, for your responses to my question. Although I am not a medical professional, much of the information contained in this post in particular and elsewhere in this blog in general helps clarify a lot of my observations as I advocated medically on behalf of my mother. It also helps me think more clearly and objectively about my own medical future.
Thank you, all.
My "pet peeve" regarding DNR orders is that the "Code Blue" is the only procedure in all of medicine where informed consent is assumed. In every other intervention we at least give lip service to weighing the benefits vs. risks.
There are cases where a resusitation effort is clearly of no benefit to the patient. CPR shouldn't even be offered. Think about a patient with lung cancer which is metastatic to the brain. Who would recommend a lung resection?
Been rethinking Curative, vs. Restorative vs. Comfort.
POLST has this paradigm:
-Comfort Measures Only
-Limited Interventions (usually delineated in POLST order)
-Full treatment
Do you all think that would be clearer to the other docs and staff?
Christian,
The POLST paradigm looks great.
Again I think its practicality depends on the target "audience" - the staff reading & interpreting those orders. If you're fortunate enough to work in a setting where the average intelligence is capable of understanding those orders, great, thats the way it should be done.
unfortunately my practice environment includes some staff (and god knows I have alot of respect for people going into nursing) whose basic communication and English skills vary widely and can sometimes pose a challenge.
Anon poster #1
Here's an interesting tidbit--
In the Joint Commission proposed standards for hospital Palliative Care, the following is identified as a sentinel event:
"Do-Not-Resuscitate patients who do not receive the same level of care that patients without Do-Not-Resuscitate orders receive."
Paul M: I'm not sure if you are any of the subsequent Anon's...?
Your point (in the 1st Anon comment) highlights some of the confusion around the term 'goals of care' including conflating goals with treatment limitations, and the vexing use of 'comfort' (without inelegant modifiers as suggested by Christian which I too use), when, god help us, comfort/symptom relief/prevention should always be a preeminent goal of all medical care regardless of what disease-modifying/curative/life-prolonging/life-sustaining/restorative measures occurring.
I recently had a conversation that went something like this (this was with a physician trainee): 'I think things are set. The patient has clear goals of care, won't go back to the ICU or be intubated again if they decline again.' Me: 'Ok, sounds good - what are the goals of care?' ...[Pause]... 'She's DNR and won't be transferred to the ICU.' Well the goals of care in this case were restorative/life-prolonging as long as the burdens of treatment don't outweigh its potential benefits, and in this case all involved had very reasonably agreed that the burdens of treatment would very much outweigh any potential benefit if the patient declined sufficiently to 'require' ICU transfer/intubation/resuscitation and so that treatment limitation was enacted in the orders, but the goals were very explicitly restorative.
So sure I was being pedantic, but the issue here underlies much of the comments, as well as Leigh's last one about the JCAHO/sentinel event thing. Orders for treatment limitations are one of the primary ways we enact/codify goals of care especially as they change as patients' prognoses worsen - we write DNR orders, clarify in the chart/orders/in sign out that the patient is not to be sent to the ICU or whatever, but the treatment limitations are not the goals (well, usually...I guess I've had a fair share of patients who very explictly defined a goal for their care as 'never do that to me again'). I think some of the breakdowns happen when people assume goals from the treatment limitations - the DNR-in-case-of-actual-cardiopulmonary-arrest patient who is not offered potentially restorative elective intubation for a reasonably reversible acute medical process; etc. etc.
Transcribing goals into a set of medical orders including treatment limitations is not easy, and issues of transparency, making sure everyone who opens the chart, is called to the bedside at 3am, can easily figure things out, are tough. In my institution there is an order set that is generally recognized as 'marking' a patient as receiving 'comfort-only' measures, no steps to be taken to reverse decline, with the expectation of death in the near future - if you actually read the orders you wouldn't be able to conclude that conclusively however - the local culture, nurse/physician understanding of what it means to put these orders on the cart, etc. - mean that it works well, but that's really a function of culture.
Anyway - my strategy is to do all of this in the progress notes plus talking directly to all key players (bedside nurse, primary team, key consultants, social services) to make sure all are understand of both goals and treatment limitations, and leave the orders for 'positive' treatments and DNR and similar orders.
I'm not convinced that doing it any other way is wise: these sorts of goals-->care plans can be highly individualistic, and based in individual historical precedent (e.g. for whatever reason the TPN is staying on, or XYZ), and cramming them into one-size-fits all order sets or phrases is often not appropriate. That, to me, is ok, and frankly a good thing - where is it written that these things are supposed to be easy - as long as you have the time and institutional culture to put all this out.
Anyway:
Paul mentioned the Curtis piece about 'Informed Assent' for DNR orders - it's a must-read for anyone interested in the issue - this blog post links to the piece and the counter editorial (scroll down to #5):
http://www.pallimed.org/2007/11/many-items-part-2.html
Just wanted to cross-link a recent post on GeriPal "Rant on Terminology" which has some interesting comments that would resonate with these comments here.
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