The ABC’s of DNR

Gary Winzelberg, MD MPHDivision of Geriatric Medicine

Palliative Care Program01/05/10

Questions

• Challenging DNR discussions• Easy discussions• Observations of attendings, fellows• Attending feedback

Internship Memory/Flashback

• Chronically ill (elderly) patient admitted with…• “Is Mr. Smith DNR?”• “I don’t know.”• “He should be.”• Pressure to get DNR order• Discomfort when caring for “full code” chronically ill

patients – What are we doing?• DNR as symbol beyond actual order

Objectives

• Historical context• Data

• CPR outcomes• Patient preferences

• Communication strategies– Approach to advance care planning on admission

DNR Order Pendulum at UNC

• 2002 – DNR order required attending approval– Overnight calls to verbally approve DNR orders

• 2009 – DNR orders written without any attending supervision– Consider code status discussions as a procedure

Cardiopulmonary Resuscitation

• Medical response to cardiac arrest• Defibrillation• Chest compressions• Medications• Intubation

“Closed-Chest Cardiac Massage”

• JAMA article, 1960• Cardiac resuscitation limited by need for open

thoracotomy and direct cardiac massage• Method of external transthoracic cardiac massage• 70% permanent survival rate, 20 patients• “Anyone, anywhere, can now initiate cardiac

resucitative procedures. All that is needed are two hands.”

CPR As Default Policy

• 1965 reclassification as universal emergency procedure that anyone could perform

• Initiate CPR regardless of medical condition• Principle that doctors should try to prevent death

“Orders Not To Resuscitate”

• 1976 NEJM article• Concern: inappropriate to apply technology to the

fullest extent in all cases and without limitation• Increased awareness of patient rights

CPR vs. DNR: Hospital Culture Tension• “Code status” dominant preoccupation of doctors &

nurses when death seems near• Doctors often don’t want to talk about code status to

sick patients or their families (& frequently don’t)• Patients & families don’t realize that they must

request DNR• Doctors feel pressure to inform patients, families of

their choice; families feel coerced, guilty, life or death responsibility

Sharon Kaufman, …And A Time To Die

“Should We Restart Your Heart?”• ER, Chicago Hope, Rescue 911 episodes (’94, ’95)• Majority of cardiac arrests caused by trauma• 28% arrests due to cardiac causes• 10% elderly• 77% short-term survival• 37% survival to discharge after CPR• CPR misrepresentations may lead patients to

generalize impressions to CPR in real lifeDiem SJ, NEJM 1996

TV vs. Reality

• Event: trauma• Age: younger adults• Rhythm: VF/VT• Short-term survival: 75%• Long-term survival:

presumed good• Function: normal

• Event: chronic illness• Age: older adults (avg 70 yo)• Rhythm: ½ VF, ½ asystole• Hospital d/c survival: 18%• Long-term survival: poor• Function: impaired

Out-of-Hospital CPR Outcomes(King County, WA)

Age Survival to Hospital Discharge

< 80 year old 19.4%81-90 9.4%> 90 4.4%VF & VT

< 80 year old 36%81-90 24%> 90 17%

Kim C, Arch Intern Med 2000

Effect of Age on Surviving CPR

• Weak association with decreased survival to hospital discharge

• OR 0.92 (0.85-0.99) for every decade• Fewer octogenarians have VF/VT

Kim C, Arch Intern Med 2000

In-Hospital CPR Outcomes (Ehlenbach WJ, NEJM 2009)

• 1992-05, >65 yo, 433,985 attempts• 18.3% survived to hospital discharge• No increase in survival during study period• Survival lower among: men 17.5% vs women

19.2%, older age (65-69 = 22% vs > 90 = 12%, coexisting illness (Deyo score >3 = 16% vs 19% if zero), admitted from SNF 11.5% vs 18.5%

• Survival higher in MI (20.4% vs 17.8%) & CHF (20.4% vs 17.1%)

In-Hospital CPR Outcomes (2)

• A-A with lower survival (14.3) compared with whites (19.2%)– A-A more likely to receive care in hospitals with lower

survival rates• Proportion of patients discharged home decreased

over time (60% to 35%)• Proportion of patients discharged to SNF increased

over time (15% to > 20%)• No data on functional outcomes

CPR Preference & Survival Probability• 371 patients, mean age 77, 84% white

Survival Rate (%) Opting for CPR (%)

1 105-10 1020-40 2250 25> 60 8Didn’t want CPR 25

Murphy DJ, NEJM 1994

Survival Probability on Patient Preferences

Chronic IllnessPatients’ estimate = 15% + 16CPR preference before learning probability = 11%CPR preference after learning probability = 5%

Murphy DJ, NEJM 1994

Functional Outcome After Hospital CPR

• 162 survivors of in-hospital CPR• 56%: same or improved function• 44%: worse function at 2 months

• Mean ADL decline: 3.9 (0-7 dependencies)• Eating, continence, toileting, transferring, bathing,

dressing, walking• Age > 75 vs. < 55: OR 5.25 worse functional status

Fitzgerald JD, Arch Intern Med 1997

Factors associated with DNR Orders

• Patient preference• 52% with DNR preference had written order

• Probability of surviving for 2 months• Age

• Orders written more quickly for patients > 75 independent of prognosis

Hakim RB, Ann Intern Med 1996

Code-Status Discussion Barriers

• Qualitative study of family physicians & residents• Personal discomfort with confronting mortality• Fear of damaging the doctor-patient relationship• Fear of harming patient by discussing death• Limited time to establish trust• Difficulty in managing complex family dynamics

Calam B, CMAJ 2000

How Do Residents Discuss CPR?

• 1992 UCSF study, audiotaped inpatient discussions• Median discussion length 10 minutes (2.5 – 36 mins)• Physician spoke 73% of time• Median time patients spoke: 2 min 30 sec• 13%: likelihood of CPR survival• 10%: discussion of patient goals, values

Tulsky JA, J Gen Intern Med 1995

Resident Approaches to Advance Care Planning on Admission Smith AK. Arch Intern Med 2006

• 2005 survey of Duke, Brigham medicine residents• 70% established CPR preference• 34% health care proxy, 36% advance directive• 32% discussed end of life care goals & values• 89% observed model of advance care planning• 37% received feedback• 47% -- goals/values important to discuss on admission

– Barriers: time, know patient better, documentation pressures

Overall Communication Approach• Establish preferred decision-makers, directives• Identify patients with clear CPR attempt preferences• Place code status in context

• Treatment decisions• Patients’ goals, values• Patients’ medical condition

• Support patients, families with end-of-life decision-making• Make recommendations• Give permission to choose approach other than disease-

oriented focus

Patients With DNR Directive

• Attempt to confirm preference• Immunity from liability for complying with a directive• Opportunity to discuss care goals, treatment

preferences• Care goals: longevity, function, comfort

• Assure patient, family that DNR does not mean “do not treat”

DNR Effects on M.D. Decision-Making• 72 yo male with advanced multiple myeloma,

dementia, admitted with deliriumTreatment DNR absent DNR present

Blood cxs 83% 82%Central line 80% 68%*Blood transfusion 87% 75%*Dialysis 20% 9%*ICU transfer 34% 16%*Intubation 35% 5%*

*p < 0.05 Beach MC, J Am Geriatr Soc 2002

Patients Without DNR Directive

• Avoid…• Should we try to restart your heart?• Should we shock you, press on your chest?• Should we not do anything?

• “Short, Tall, Grande” discussions• Communication hygiene

• Sit down• Privacy

“Short” DNR Discussion (1)• Who would the patient want to communicate with

physicians, make decisions if incapacitated?• Has the patient discussed care preferences?• Advance directive? Why?• What thoughts have you had about how you’d like

to be treated if your condition worsened, if you became much sicker than you are now?

• State your goal: treat the patient as consistent with his preferences/values as possible

“Short” DNR Discussion (2)• Framing, reflecting information content from

patient/family – demonstrate that you’ve listened• There’s an intervention that can be attempted if your

so heart stops…From what you’ve said it sounds as if…

• Share likely outcome: There’s a low/extremely low chance that you would survive and regain your current level of function

• We would focus on making sure that you’re comfortable

• Alleviate caregiver guilt

“Tall” DNR Discussion• Ask about the patient’s story (establish trust)• How do you think you’ve been doing?• Elicit goals

• What things are most important to you in your day-to-day life?

• What are your priorities? Longevity, function, comfort• Caution re: quality of life discussion

• Focusing on your function, comfort would mean…translate information into specific treatment recommendations (place DNR in context of care plan)

Communication Documentation

• Use advance care planning template in Webcis• Central location for data (phone numbers)• Describes content of communication• Assists with continuity of discussions among

physicians

Key Communication Elements• Trust

• Encourage patients, families to talk• Demonstrate respect• Do not force decisions

• Uncertainty• Make recommendations• Allow patients, families to reject recommendations

• Affect• Hope

• Focus on the positiveTulsky JA, JAMA 2005

Summary

• CPR – DNR tension for hospitalized patients• Outcomes poor for chronically ill patients• Age: weak predictor of outcome• Communication essential to understanding patient,

family preferences• DNR considered in context of other treatment

decisions, patients’ goals

References

1. Quill TE. Initiating End-of-Life Discussions With Seriously Ill Patients. JAMA 2000

2. Tulsky JA. Beyond Advance Directives: Importance of Communication Skills at the End of Life. JAMA 2005

3. Winzelberg GS, Hanson LC, Tulsky JA. Beyond Autonomy: Diversifying End-of-Life Decision-Making To Serve Patients and Families. J Am Geriatr Soc 2005

4. Ann Intern Med communication articles