Not For Resuscitation(NFR) order in Elderly Patient

Presented By Rakesh Patel

Registered Nurse

Today’s Talk Will Cover

• NFR order in elderly patient• Benefit of having NFR status • When to have NFR order • Advance care planning (ACP) • What it means & how to approach– Tools to help you plan

• Care of patient who has signed NFR form.– Common challenges & how to approach

Abbreviations Used in This Talk

• NFR: Not for resuscitation • DNR: Do not Resuscitate.• EOL: End of life• Palliative care• ACP: Advance care planning• AD: Advance directive• DPOAH: Durable power of attorney for health care• POLST/MOLST: Physicians/Medical Orders for Life-

Sustaining Treatment

NFR means

Not for resuscitate (NFR) order, a written medical directive that documents a patient's decision regarding his/her desire to avoid cardiopulmonary resuscitation (CPR) in Case of cardiac arrest .

• (Butka, B. 2012:1613-1613)

Cardinalethical points

• Autonomy• Not Malefiency• Justice• Beneficial

(Santonocito,. C. 2013: 14–21)

Benefits of NFR order

• Helps elderly and terminally ill patient get the preferred care:– For those who prefer this: can increase chance of dying at

home, decrease hospitalizations at end of life• Reduces decision-making stress for surrogate decision-

maker.• Can reduce family conflicts over what should be done• NO CPR related complication.• To redirect finite resources to more‘salvageable’ patients(Downar, J., Luk, T., Sibbald, R. W., Santini, T., Mikhael, J., Berman, H., & Hawryluck, L. 2011: 582-587).

steps for planning NFR

1. Understand health conditions and how they are likely to progress– Hope for best, prepare for likely crises/declines

2. Articulate values and preferences for future care– Includes designating a surrogate decision-maker

3. Document preferences in writing4. Re-assess preferences and plans periodically

EXAMPLES WHERE NFR CAN BE USED

• Advanced incurable malignancy• advanced multi-organ failure• irreversible, severe, and documented brain damage • advanced cardiac, hepatic, or pulmonary disease • inoperable, life threatening congenital heart disease, fatal chromosomal or

neuromuscular disease • Irreversible, severe, mental and physical incapacity. • Advanced incurable, end-stage malignancy • End-stage organ failure • Advanced irreversible brain damage • End-stage renal disease if renal replacement therapy is not feasible • Inoperable congenital anomalies incompatible with life • Fatal chromosomal abnormalities • Brain death.

COMPONENTS OF A NFR ORDER

• Cardiopulmonary resuscitation involving chest compressions and oxygenation

• Endotracheal intubation• Mechanical ventilation• Defibrillation• Vaso-active/ionotropic medication

NFR with Choice

• Renal dialysis• Blood transfusion• Parenteral nutrition• Pulmonary hygiene• Normal treatment Including antibiotics

Preferences & Values for Future Care

• What are the Value of Terminal illness person value?– What matters most in life?– What makes life worth living? What sounds worse than

death?– What would be an ideal last year? An ideal death?– Feelings about life support? About being hospitalized?

About surgeries? About suffering?– At what point, if any, should doctors stop trying to extend

life?(Sulmasy, D. P., He, M. K., McAuley, R., & Ury, W. A 2008: 1817-1822)

Example of patient wishes

• – "if I deteriorate I do not want resuscitation or to go to

• intensive care, I want to be kept comfortable and dry”

• – "I want to die at home and not return to hospital"

• – “Please make sure that I die outside, under the stars”

Document Preferences in Writing• Print or hand-write key points from the process of reflecting &

discussing– This information can later help family members & clinicians

• Complete a state-approved NFR form– Review with primary care doctor or other clinician if possible

• Consider appending key information regarding preferencesConsider POLST/MOLST (Physician/Medical Orders for Life-Sustaining Care)– Bright-colored paper, summarizes key preferences re resuscitation &

transfer to hospital– Meant to guide clinicians during a medical emergency– Signed by physician & by patient/DPOAH

Diffrenent form oF NFR Writing

• written bedside orders• wallet identification cards• identification bracelets• predefined paper documents

(Loertscher, L., Reed, D. A., Bannon, M. P., & Mueller, P. S. 2010:4-9)

NSW health NO CPR order form

Barrier to have NFR order

• cultural resistance • Poor communication between patients and doctors • NFR plan are not easily accessible• No systems in place to have NFR• Lack of time in Emergency department to discuss NFR.• Religious belief• Language • Ethics (Fromme, E. K., Zive, D., Schmidt, T. A., Olszewski, E., & Tolle, S. W. 2012: 34-35)

SUPPORTIVE CARE FOR ALL NFR PATIENTS

• Clearance of secretions (oral, throat, etc)• Hydration and nutrition• Pain management, antipyretics, and sedation• Supplemental oxygen• Anti emetics and relieve of constipation• Relief of urinary retention• Relief of dypnea and cough)

RECOMMENDATIONS• Develop palliative care as an alternative to ICU for DNR.• Training workshops on the ethical issues of EOL• DNR orders to specify interventions

intended/prohibited• Respecting the autonomy of physicians who have

conscientious objections to DNR• More psycho-social support for DNR families• More empirical research on the DNR process• Regular audits of DNR decisions and outcomes.

PROTECTION OF THE PATIENT FROM POTENTIAL HARM

• Paternalism• Patient consent for CPR• Patient consent for DNR• Family assent to DNR• Age discrimination

Reassess preferences & plans periodically

• Preferences will change over time, as health evolves.

• Consider reviewing advance care planning – After new major diagnosis, such as cancer or other

life-limiting illness– After major hospitalization– After significant decline in health or abilities

(NSW health policy 2011 and Ambulance service of NSW)

The Role of Caregivers

• Caregivers often advocate for the comfort & needs of person with dementia

• Caregivers are often surrogate decision-makers• Many families don’t understand how people

with advanced dementia decline & die– Better understanding linked to fewer

hospitalizations in last 18 months of life• (Weeks, L.E., MacQuarrie, C. & Bryanton, O. 2008:85-93)

The Role of Palliative Care• Palliative Care: • Assessment and Treatment of Symptoms• Psychosocial, Spiritual, and Bereavement Support• Coordination of Care

– Care focused on symptoms and quality of life– Providers have special training in communicating with families and in

addressing concerns– Does not equal hospice, or “giving up” (but families sometimes

choose hospice if preferences & situation are a good fit)

– (Morrison, R.S. & Meier, D.E., M.D. 2004:2582-2590)

Benefit of Treatment vs. Burden on Patient

• Are we keeping the patient alive when there is no benefit to the life of the patient?

• Are we giving the patient time to recover to a level of quality of life that the patient will accept,

• Or are we merely prolonging or exacerbating the process of death?

References

• • Butka, B. 2012 Do Not Resuscitate. Journal of American medical association 308 16, 1613-1613• Cohen, R. I., Lisker, G. N., Eichorn, A., Multz, A. S., & Silver, A. 2009 The impact of do-not-resuscitate order on triage decisions to a medical intensive care

unit. Journal of critical care, 24 2, 311-315.• Downar, J., Luk, T., Sibbald, R. W., Santini, T., Mikhael, J., Berman, H., & Hawryluck, L. 2011 Why do patients agree to a “Do not resuscitate” or “Full code” order?

Perspectives of medical inpatients. Journal of general internal medicine, 26(6), 582-587.• Field, J. M., Hazinski, M. F., Sayre, M. R., Chameides, L., Schexnayder, S. M., Hemphill, R., & Hoek, T. L. V. 2010 Part 1: executive summary 2010 American Heart

Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 122 18 suppl 3, S640-S656.• Fromme, E. K., Zive, D., Schmidt, T. A., Olszewski, E., & Tolle, S. W. 2012 POLST Registry do-not-resuscitate orders and other patient treatment

preferences. JAMA, 307 1 , 34-35.• Handy, C. M., Sulmasy, D. P., Merkel, C. K., & Ury, W. A. 2008 The surrogate's experience in authorizing a do not resuscitate order. Palliative and Supportive

Care, 6 01, 13-19.• Levin, T. T., Li, Y., Weiner, J. S., Lewis, F., Bartell, A., Piercy, J., & Kissane, D. W. 2008 How do-not-resuscitate orders are utilized in cancer patients: timing relative

to death and communication-training implications. Palliative and Supportive Care, 6(04), 341-348.• Loertscher, L., Reed, D. A., Bannon, M. P., & Mueller, P. S. 2010 Cardiopulmonary resuscitation and do-not-resuscitate orders: a guide for clinicians. The

American journal of medicine, 123 1, 4-9.• Sulmasy, D. P., He, M. K., McAuley, R., & Ury, W. A 2008 Beliefs and attitudes of nurses and physicians about do not resuscitate orders and who should speak to

patients and families about them. Critical care medicine, 36(6), 1817-1822.• Sulmasy, D. P., Sood, J. R., & Ury, W. A. 2008 Physicians’ confidence in discussing do not resuscitate orders with patients and surrogates. Journal of medical

ethics, 34(2), 96-101.• Venneman, S. S., Narnor-Harris, P., Perish, M., & Hamilton, M. (2008). “Allow natural death” versus “do not resuscitate”: three words that can change a

life.Journal of Medical Ethics, 34(1), 2-6.• Santonocito, C. 2013 Do-not-resuscitate order: a view throughout the world. Journal of • Critical Care 28, 14–21.• Ventafridda,V.2006 Palliative Medicine 2006; 20: 159• Morrison, R.S. & Meier, D.E., M.D. 2004, "Palliative Care", The New England journal of medicine, vol. 350, no. 25, pp. 2582-90. • Weeks, L.E., Macquarie, C. & Bryant on, O. 2008, "Hospice Palliative Care Volunteers: a Unique Care Link", Journal of palliative care, vol. 24, no. 2, pp. 85-93.