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8/8/2019 Webmm.ahrq.Gov.25 Slideshow
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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.