The ABC’s of DNR
Gary Winzelberg, MD MPH
Division of Geriatric Medicine
Palliative Care Program
01/05/10
Questions
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Challenging DNR discussions
Easy discussions
Observations of attendings, fellows
Attending feedback
Internship Memory/Flashback
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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
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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?”
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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 life
Diem SJ, NEJM 1996
TV vs. Reality
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Event: trauma
Age: younger adults
Rhythm: VF/VT
Short-term survival: 75%
Long-term survival:
presumed good
• Function: normal
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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
< 80 year old
81-90
> 90
VF & VT
< 80 year old
81-90
> 90
Survival to Hospital Discharge
19.4%
9.4%
4.4%
36%
24%
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)
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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
10
5-10
10
20-40
22
50
25
> 60
8
Didn’t want CPR
25
Murphy DJ, NEJM 1994
Survival Probability on Patient Preferences
Chronic Illness
Patients’ estimate = 15% + 16
CPR 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
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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?
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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
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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 decisionmaking
• Make recommendations
• Give permission to choose approach other than diseaseoriented 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 delirium
Treatment
Blood cxs
Central line
Blood transfusion
Dialysis
ICU transfer
Intubation
*p < 0.05
DNR absent
83%
80%
87%
20%
34%
35%
DNR present
82%
68%*
75%*
9%*
16%*
5%*
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
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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 positive
Tulsky JA, JAMA 2005
Summary
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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
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Quill TE. Initiating End-of-Life Discussions With Seriously
Ill Patients. JAMA 2000
Tulsky JA. Beyond Advance Directives: Importance of
Communication Skills at the End of Life. JAMA 2005
Winzelberg GS, Hanson LC, Tulsky JA. Beyond
Autonomy: Diversifying End-of-Life Decision-Making To
Serve Patients and Families. J Am Geriatr Soc 2005
Ann Intern Med communication articles