DNR Orders,
Death Pronouncement and
Notification
Matthew S. Ellman, MD
ICM,
March, 2010
Content
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How to talk with patients about DNR orders
How to do death pronouncement
Death notification
Advance Directives
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Laws and forms vary
2 types:
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Health care power of attorney
Living will
Misconceptions
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Advanced Directive means “don’t treat”
Named proxy means pt loses control
Only old people need advance directives.
Advance Directives/DNR discussions:
Hospital Admissions
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Start with goals of care and clinical scenario.
“Perfunctory” vs. life-threatening condition
“Perfunctory”
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Normalize
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“Hospital policy tells us that we should talk with all
patients admitted about their wishes regarding
health treatment preferences, including advance
directives and cardiopulmonary resuscitation”
Opportunity to
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elicit patient concerns/fears
clarify misconceptions about condition, prognosis,
and treatment options.
DNR orders in the Hospital
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Establish goals of care
Do your homework!
CPR Outcomes
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Survival 20 minutes after CPR
44%
Survival to discharge
17%
VT/VF survival to d/c: 35%
Pulseless or asystole survival to d/c:10%
Pre-CPR 84% came from home; among survivors
51% returned home
“Talking points” for patients
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17% or 1 in 6 who undergo CPR in the
hospital may survive to discharge
Specific co-morbidities reduce survival
Surviving patients at risk for CPR related
complications
DNR Discussion: 6 steps
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6.
Establish setting
What does patient understand?
What does patient expect/goals of care?
Discuss DNR order
Respond to emotion
Establish a plan
Establish setting
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Ensure comfort, privacy
Ask who should be present
Open generally: “I’d like to speak with you
about possible health care decisions in the
future”
What does patient understand?
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Understanding illness / prognosis for
necessary for informed decision
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“What do you understand about your health
situation?”
Get the patient talking
If understanding inaccurate-- now is time to
review/correct
What does the patient expect?
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Ask/listen:
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“What do you expect in the future?”,
“What goals do you have for the time you have left?”
If unrealistic, clarify
Ask pt. to explain values underlying preferences.
Clarify/confirm
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E.g.: “So what you’ve said is that you want us to do
everything we can to fight but when the time comes, you
want to die peacefully”
Unreasonable requests for CPR
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Inaccurate information about CPR
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General public: CPR works 60-85%
Patient and family hopes, fears and guilt
Distrust of medical care system
Prognosis (median survival):
Common cancer syndromes
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Malignant hypercalcemia: 8 weeks (except
newly diagnosed myeloma or breast)
Malignant pericardial effusion: 8 weeks
Carcinomatous meningitis: 8-12 weeks
Multiple brain mets.: 3-6 mos. with RT, 1-2
mos without.
Malignant ascites, pleural effusion, bowel
obstruction: < 6months.
Discuss DNR order
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Use language patient understands
Don’t introduce CPR in mechanistic terms:
“…intubation, CPR, press on your chest, tube down
your throat, mechanical ventilation”
Consider using word “die” or “if heart stops/unable
to breath on your own”: clarifies that CPR is
treatment tries to reverse death.
Never say: “Do you want us to do everything?”
Discuss DNR order
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If appropriate, make clear recommendation
against CPR.
“We have agreed that the goals of care are to
keep you comfortable…with this in mind I do
not recommend the use of artificial or heroic
means to keep you alive. If you agree, I will
write an order in your chart that if you die, no
attempt to resuscitate you will be made.”
DNR discussion
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If prognosis unclear and/or goals uncertain,
ask about CPR
“If you should die (or if your heart stops or
you are unable to breath on your own) in
spite of all our efforts, do you want us to use
heroic measures to attempt to bring you
back?”
If asked to explain: Describe purpose, risks
and benefits of CPR.
Respond to Emotion
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Strong emotions responses common, brief
N.U.R.S.
Silence may be best, reassuring touch,
tissues.
Establish a plan
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Clarify orders for overall goals, not just DNR
status
Do not use DNR as proxy for other
treatments
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“We will continue maximal medical therapy to meet you
goals, however if you die, we won’t use CPR to bring you
back”
Or: “It sounds like we should move to a plan to maximize
your comfort, so in addition to DNR order, I will ask our
palliative care team to see you.”
Video
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Look for 6 steps
What did MD do that did/did not work well?
Think about what have you seen on the
wards
Death Pronouncement
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More than actual declaration of death
3 key steps
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Examining patient to determine death
Record proper documentation
Notifying families
Ref: www.mcw.edu/EPERC/FastFactsandConcepts, Heidenriech and
Weissman, MD, 2000
“Please come to pronounce this patient”
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Preparation
In the room
Pronouncement
Documentation medical record
Notification – attending, relatives
Coroner’s/M.E. Reportable Case
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If patient in hospital <24 hours
If death unexpected, unusual circumstances
If death assoc w/trauma or a procedure
Death during surgery or anesthesia
Other - varies by state law
Pronouncement Video Clips
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Observe
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MD behavior
Daughter’s reactions
What you have seen in the hospital?
Informing Significant Others
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Family and friends look to MD for
information, reassurance and direction
Lasting impressions and memories
Affects grief process, integration of loss
Overview of Notification
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Preparation
Meeting with family/significant others
Follow-up
Notification: preparation
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Confer with nursing, other staff
Review record
Examine patient
Find private place to meet
Involve other members of team
Learn names of those you will talking to and
relationship to deceased
Notification: Meeting with significant
others
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Introduce yourself, identify others
Invite to sit down with you
Use eye contact & touch if appropriate
Express condolence: “I’m sorry for your loss”
Talk openly about death – use “died’ or
“dead” initially, then use words family uses
Identify, respect culture & religion
Meeting with significant others
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If requested, explain cause of death in nonmedical terms
Offer assurance everything done to keep
person comfortable
Be prepared: range of emotion
Offer opportunity to see deceased
Prepare family
Seeing the deceased with significant
others
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Model touching & talking to deceased
Offer time alone, assure no rush
Provide time to process before discussing
autopsy/ organ donation
Offer to return should questions arise
Provide info for family to reach you
Follow-up
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Personalize sympathy card
Consider attending wake, funeral
Consider referral to bereavement support
Encourage bereaved to see MD in 4-6 mos.
Invite bereaved to meet with you re:
questions/concerns; autopsy results
Organ donation request
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Determine eligibility ahead of time
OPO & med. team should approach family together
When? - after family realizes loved one will die
OD cards are legally binding – tell don’t ask family
Communication correlates of donation:
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Discussing specifics, incl. issues of cost, effects on funeral
Family spending time with OPO staff
Psychosocial support for grieving family
Autopsies: how families may benefit
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Discover inherited/familial/(infectious) conditions
Uncover work-related disease
Provide info. to settle insurance/death benefits
Ease stress of unknown; finding dx/tx appropriate
may provide comfort
Medical knowledge gained may help others which
may help ease pain of loss
Autopsies: common concerns
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Body treated w/respect & dignity; family
wishes maintained all times
Cost – usually none in teaching hospitals
Should not delay funeral or affect viewing
Some organs may be kept for detailed exam
Most major religions leave decision to nextof-kin
Telephone Notification
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Can be challenging & stressful
Dilemma: on the phone or ask to come in?
Factors to consider:
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Death expected or not
Relationship to and how well you know family
Anticipated emotional reaction
Whether person will be alone, level understanding
Distance, transportation, time of day
Telephone Notification
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Prepare for the call
Find quiet place to phone
Call as soon as possible
When delay likely, responsibility should be
taken by covering MD
Telephone Notification
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Identify yourself
Identity of person reach
Ask to speak with person closest, ideally:
proxy or contact person
Avoid responding until you have verification
of identity
No notification to minors
Telephone Notification: What to say
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1.
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6.
Buckman: “giving bad news”
Prepare
What does patient know
(What does patient want to know)
Share the news (“warning shot”)
Respond to emotion
Plan
Phone notification: what to say
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If no prior relationship, ask what they know of
condition: “What have MDs told you…?”
Warning shot
Clear direct language: “I’m sorry, ----- has just
died.” (not “expired”, “passed away”, “didn’t
make it”)
Speak clearly & slowly
Allow time for questions
Be empathic
Phone notification: considerations
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Arrange to meet family
Ask if you can contact anyone for them
Do not leave news on voice mail
If no contact in 1-2 hours – use social work
If you feel uncomfortable, ask for help
Conclusions
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Observe role models, mentors
Prepare
Keep the dialogue patient-centered
Respond to emotion
Remember: patients will not forget