Assessing and Improving the Understanding of DNR/DNI among

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Understanding Code Status Course: Assessing and Improving the
Understanding of DNR/DNI among Medical Students and Residents
Aroonsiri
1
(June)Sangarlangkarn ,
MD, MPH, Margaret
2
Drickamer ,
MD
1Yale
Internal Medicine Residency Program, New Haven and Waterbury, CT
2Department of Geriatrics, Yale School of Medicine, New Haven, CT
INTRODUCTION
• Many studies demonstrate continued deficiencies in physicians’ education
about end-of-life care (ACGME, ABIM)
• There is limited literature on how health care providers understand the
meaning and ramifications of DNR/DNI
RESULTS
Figure 5. Comparison of Participants with Adequate
Understanding of DNR/DNI Before and After the Course (n=44)
Figure 2. Percentage of Participants Who Would
Recommend the Course to Others (n=44)
Figure 1. Percentage of Course Participants by Type (n=44)
35.00%
14
14
14
60.00%
30.00%
25.00%
• Our study aims to assess:
1. The understanding of DNR/DNI among physicians in training
2. The efficacy of case-based learning in code status education
15.00%
10.00%
5.00%
Medical student
Intern
Resident
40.00%
30.00%
30.00%
20.00%
20.00%
3
10.00%
Strongly
Agree
100.00%
40
38
80.00%
Agree
Neutral
Disagree
Strongly
Disagree
41
DNI
Before
40.00%
DNR
After
20.00%
0.00%
NPPV
27
26
60.00%
21
21
26
14
Before
11
After
20.00%
10.00%
4
3
3
After
4
3
1
4 Agree
3 Neutral
2 Disagree
1 Strongly
Disagree
Odds Ratio
Ambu-bag
11
NPPV
2
Chest Compression
∞
Defibrillation
1
Epinephrine
1.75
Amiodarone
9
Bicarb
3
Ambu-bag
0.5
Intubation
2.33
95% CI
(1.60, 473.47)
(0.10, 117.99)
(0.03, ∞)
(0.01, 78.50)
(0.44, 8.15)
(1.25, 394.48)
(0.75, 17.23)
(0.13, 1.61)
(0.53, 13.98)
p-value
0.0063
1.0000
1.0000
1.0000
0.5488
0.0215
0.1460
0.3018
0.3438
22
40.00%
30.00%
8
 Many physicians in training fail to offer manual lung inflation and NPPV
to DNI patients in respiratory distress. After the course, participants are
11 times more likely to correctly offer manual lung inflation to DNI
patients in respiratory distress.
70.00%
50.00%
10
DISCUSSION AND CONCLUSION
Figure 4. Comparison of Participants Who Would Provide the Following Interventions to
DNR Patients in Cardiopulmonary Arrest Before and After the Course (n=44)
22
Before
Table 1. Odds Ratio of Correctly Answering Survey Questions After the Course
60.00%
Ambu-bag
12
5 Strongly
Agree
28
Intubation
17
0.00%
Other
14
 Weissman DE et al. ACGME Requirements for End-of-life Training in
Selected Residency and Fellowship Programs: A Status Report. Acad Med
2002;77:299-304
40.00%
Figure 3. Comparison of Participants Who Would Provide the
Following Interventions to DNI Patients in Respiratory
Distress Before and After the Course (n=44)
 Qualitative surveys:
 September-October 2011, before and after case-based learning course
administered at noon conference attended by medical students and
residents as part of Yale School of Medicine internal medicine rotations
 Evaluate improvements in responses using exact Mcnemar test
 Blank LL. Overview on ABIM end-of-life patient care project: caring for
the dying: identification and promotion of physician competency. Hosp
J 1998;13: 145-50
18
0.00%
 Case-based learning course:
 Similar format as Yale Office-Based Medicine Curriculum – literaturebased interactive course that provides an evidence-based approach to
clinical practice used by residency programs across the US
 Three challenging end-of-life cases focusing on DNR/not DNI patients,
reversibility, futility
REFERENCES
50.00%
0.00%
METHODS
 Survey content:
1. DNI section: What can you give a DNI patient who has a pulse but is
in respiratory failure? (check all that apply)
2. DNR section: What can you give a DNR patient in cardiopulmonary
arrest? (check all that apply)
3. Adequate understanding of what DNR/DNI means?: 5 (strongly agree)
to 1 (strongly disagree)
4. Would you recommend this course to others?: 5 (strongly agree) to 1
(strongly disagree)
60.00%
10.00%
2
32
70.00%
23
50.00%
20.00%
• There is limited literature on validated teaching tools on the ramifications
of DNR/DNI on patient care for health care providers
80.00%
 Many physicians in training would provide contraindicated interventions
to DNR patients in cardiopulmonary arrest. After the course, participants
are 9 times more likely to correctly forego antiarrhythmic agents such as
Amiodarone in DNR patients with cardiopulmonary arrest.
 There was 0.93 point increase in participants who reported adequate
understanding of DNR/DNI after the course (p=0.000). While 7% of the
participants feel neutral, 93% would recommend the course to others.
3
0.00%
Chest
Defibrillation Epinephrine Amiodarone Bicarbonate
Compression
Ambu-bag
Intubation
Physicians in training may benefit from education on code statuses,
particularly case-based learning which may improve their understanding
of DNR/DNI and enhance the quality of end-of-life discussions
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