DNR Orders, Death Pronouncement and Notification

Matthew S. Ellman, MDICM, March, 2010

Content

1. How to talk with patients about DNR orders

2. How to do death pronouncement

3. Death notification

Advance Directives

Laws and forms vary 2 types:

– Health care power of attorney– Living will

Misconceptions – Advanced Directive means “don’t treat” – Named proxy means pt loses control – Only old people need advance directives.

Advance Directives/DNR discussions: Hospital Admissions

Start with goals of care and clinical scenario. “Perfunctory” vs. life-threatening condition

“Perfunctory”

Normalize – “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 – elicit patient concerns/fears– clarify misconceptions about condition, prognosis,

and treatment options.

DNR orders in the Hospital

Establish goals of care Do your homework!

CPR Outcomes

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

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

1. Establish setting

2. What does patient understand?

3. What does patient expect/goals of care?

4. Discuss DNR order

5. Respond to emotion

6. Establish a plan

Establish setting

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?

Understanding illness / prognosis for necessary for informed decision– “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?

Ask/listen: – “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

– 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

Inaccurate information about CPR– General public: CPR works 60-85%

Patient and family hopes, fears and guilt Distrust of medical care system

Prognosis (median survival): Common cancer syndromes

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

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

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

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

Strong emotions responses common, brief N.U.R.S. Silence may be best, reassuring touch,

tissues.

Establish a plan

Clarify orders for overall goals, not just DNR status

Do not use DNR as proxy for other treatments

– “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

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

More than actual declaration of death 3 key steps

1. Examining patient to determine death

2. Record proper documentation

3. Notifying families

Ref: www.mcw.edu/EPERC/FastFactsandConcepts, Heidenriech and Weissman, MD, 2000

“Please come to pronounce this patient”

1. Preparation

2. In the room

3. Pronouncement

4. Documentation medical record

5. Notification – attending, relatives

Coroner’s/M.E. Reportable Case

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

Observe – MD behavior– Daughter’s reactions

What you have seen in the hospital?

Informing Significant Others

Family and friends look to MD for information, reassurance and direction

Lasting impressions and memories Affects grief process, integration of loss

Overview of Notification

Preparation Meeting with family/significant others Follow-up

Notification: preparation

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

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

If requested, explain cause of death in non-medical 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

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

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

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:

– 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

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

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 next-

of-kin

Telephone Notification

Can be challenging & stressful Dilemma: on the phone or ask to come in?

Factors to consider:– 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

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

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

Buckman: “giving bad news”

1. Prepare

2. What does patient know

3. (What does patient want to know)

4. Share the news (“warning shot”)

5. Respond to emotion

6. Plan

Phone notification: what to say

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

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

Observe role models, mentors Prepare Keep the dialogue patient-centered Respond to emotion Remember: patients will not forget