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Source and Credits

This presentation is based on the July 2003

AHRQ WebM&M Spotlight Case

See the full article at http://webmm.ahrq.gov CME credit is available through the Web site

Commentary by: Bernard Lo, MD, University of California, San Francisco;

James A. Tulsky, MD, Duke University Medical School

Editor, AHRQ WebM&M: Robert Wachter, MD

Spotlight Editor: Tracy Minichiello, MD

Managing Editor: Erin Hartman, MS

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Objectives

At the conclusion of this educational activity, participants should

be able to:

Appreciate challenges of determining goals of care inhospitalized patients

Understand common misconceptions about CPR

List typical mistakes physicians make when discussing advanced

care planning Recognize steps physicians and health care systems can take to

improve advanced care discussions

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Case: Code Status Confusion

A 60-year-old woman with a history of severe asthma without prior

intubations presented to the ER with shortness of breath. On

physical examination, her BP was 145/85, HR 85,O2sat 94%witha respiratory rate of22. Her lung exam revealed diffuse-end

expiratory wheezes and decreased breath sounds at the bases.

Despite a long-standing relationship with a PCP, the patient had

neither designated a health care proxy nor completed a living will

prior to admission.

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Advanced Directives

75% of patients who present to the ER do not haveadvanced directives

Even fewer in absence of terminal diagnosis

When completed, advanced directives are oftenunavailable upon hospitalization or are difficult tointerpret

Hospital-based physicians often discuss code statuswith patients they have not met previously

Ishihara KK, et al. Acad Emerg Med. 1996;3:50-3.

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Patients Preferences Regarding CPR

30% of patients with serious underlying illness do not

want resuscitation Physicians cannot accurately predict patients

preferences without asking them

Hofmann JC, et al. Ann Intern Med. 1997; 127:1-12.

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Case (cont.): Code Status Confusion

Upon admission, the intern spoke with the patient about code

status. The patient stated that she would not want to be on a tube

to breathe. About CPR, she did not want shocks to the heart orpressing on my heart. She said if her breathing continued to be this

difficult and she could not live independently, she would rather not

survive. The intern interpreted these statements as indicating the

patients desire for DNR status, and called the resident to discuss it,

but a DNR form was not completed at that time.

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Common Features ofCode Status Discussions

Use of vague language

Would you want your life prolonged? Use of dire scenarios

Only 50% of MDs present scenarios with reversibleconditions

Failure to elicit patient concerns and discuss goals ofcare Rarely clarify small chance recovery, poor quality of life

Tulsky JA, et al. Ann Intern Med. 1998;129:441-449.

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Domination of discussion by physician

Physicians speak nearly three-fourths of the time

Use of medical jargon

Without confirming patients understanding

Common Features ofCode Status Discussions

Tulsky JA, et al. J Gen Intern Med. 1995;10:436-442.

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Do Patients Understand CPR?

Survey results: patients have misconceptions even after

discussions:

CPR survival estimated to be 70% (in reality is 10%-15%)

26% could not identify features of CPR

37% thought ventilated patients could talk

20% thought ventilators were O2 tanks

20% thought people on ventilators were in a coma

Fischer GS, et al. J Gen Intern Med. 1998;13:447-454.

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Theresidenthaddiscussedthecasebrieflywiththe

intern(includingherinterpretationthatthepatientwished

tobeaDNR),butneithertheresidentnortheattending

haddiscussedcodestatuswiththepatient.Atthistime,

thepatientsbloodpressurewas90/palpable,heartrate

was40andanO2 saturationwas92%withassistedbag-

maskventilation.

Case(cont.): CodeStatusConfusion

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The Code Status Dilemma

DocumentationNo code status documented in chart;therefore, code initiated

AutonomyPatient had expressed wish to be DNR to intern onadmission

BeneficenceTeam knew prognosis of witnessed arrest fromasthma exacerbation was good

Informed decision makingTeam concerned patient was not

fully informed when she requested to be DNR on admission This is the only ethical justification for overriding a DNR order

Lo B. Promoting the patients best interests. In:Resolving ethical dilemmas:A guidefor clinicians (2nd ed.). 2000:30-41.

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Thepatientdidreceivecardiopulmonaryresuscitation,

includingmedicationsandchestcompressions. Inan

efforttorespectherpreferencetoavoidinvasive

ventilation,shewasstartedonnoninvasivebi-level

positiveairwaypressure(BIPAP)ventilation.

SpontaneousrespirationsreturnedwithBIPAP,andthe

patientwasstabilized.

Case(cont.): CodeStatusConfusion

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Thenextday,thepatientwasalertandabletoexpress

herthoughtsabouttheeventsofthepreviousnight. She

hadnotrealizedthatintubationcouldbeatemporizing

measureshethoughtitmeantpermanentrespiratory

support. Shehadthoughtthediscussionwasabout

whethershewouldwanttobekeptaliveifshewasa

vegetable.

Case(cont.): CodeStatusConfusion

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Case (cont.): Code Status Confusion

Furthermore, the patient said that she had

not realized that resuscitation attempts could be

successful.Afterherexperience, she stated that she

did want aggressive interventions forreversible causes.

Hercode status was changed to fullcode.

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Tips for Discussing Advanced Directives

Do more listening and less talking

Elicit patients values and overall goals of carematch

interventions with these goals

Use simple language

Make clear the alternative to CPR is death, andexpress the likely survival after CPR. Distinguish situations where outcomes are better, such as in

the OR or during conscious sedation for procedures

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Ask about preferences in scenarios with uncertainoutcomes

i.e., successful cardiac resuscitation with resultant severeanoxic brain injury

Assess the patients understanding Especially if decision is contrary to what would be expected

in similar patients

Reassess the patients goals of care at everyhospitalization

Tips for Discussing Advanced Directives

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Recommendations for Hospitalsand Educators

Standardize the DNR order sheet

Separate authorization for CPR, intubation, and vasopressors

Consider including other life-prolonging interventions (i.e.,

tube feeds, antibiotics, dialysis) that may be instituted in

patients who will not receive CPR

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Teach residents and medical students how to elicit

patients preferences and goals of care

Do not rely on lectures alone

Observe trainees conducting advanced directives

discussions and give feedback

Consider role playing, video-taped sessions, and standardized

patients

Provide opportunities for trainees to observe seasoned

clinicians discussing goals of care

Recommendations for Hospitalsand Educators

Tulsky JA, et al.Arch Intern Med. 1996;156:1285-1289.

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Promote interactions between hospital-based and

primary care physicians Ideally, hospital-based housestaff and hospitalists would

talk to these physicians before writing DNR or DNI orders

Recommendations for Hospitalsand Educators

Lo B.Am J Med. 2001;111:48-52.