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Modules:

  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Back to Module 11: Withholding/Withdrawing Treatment
    Three Applications

    Example 1: Artificial Feeding and Hydration
    Example 2: Ventilator Withdrawal
    Example 3: Cardiopulmonary Resuscitation (CPR)

    Example 3: Cardiopulmonary Resuscitation (CPR)

    A Brief Overview

    • Many physicians perceive discussion about cardiopulmonary resuscitation (CPR) to be difficult
    • Successful approaches not customarily demonstrated during medical training
      • At best, the attending physician conducted such discussions alone, behind closed doors

      • At worst, these discussions were assigned to a lone medical student or resident to do after rounds
      Reflect on the Language of CPR
      It is worth reflecting on the language that has developed around CPR and do-not-resuscitate (DNR) status, particularly in hospitals. Getting the DNR order is an important goal for physicians. The phrases, "She is a DNR" or, "He is a full code" betray the bizarre way in which decisions about resuscitation are sometimes treated in contemporary medical care. "Is he or she a DNR?" has become shorthand for the more pertinent question, "What are the goals of care?" Too frequently, a DNR order is interpreted to imply a whole host of other decisions that, in fact, may or may not have been made about an individual patient
      One impetus to the current state of affairs is the emotional subtext related to "doing everything" for someone who is loved. It should be expected that everyone involved—patient, family, physician, health care team—wants to do everything possible to achieve the health and well-being of the patient. Cardiopulmonary resuscitation is but one medical treatment that may or may not help to achieve realistic goals related to the care of the patient

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    Physicians Role

    • Facilitate the identification of those goals of care
    • Help to determine the medical care that will best achieve them
      • In the setting of advanced progressive illness with limited prognosis, consider carefully whether CPR will help achieve goals that patient, family and the physician have collectively determined

      • Using this approach, discussion of CPR and DNR status become deemphasized to the point that they almost disappear as important parts of the discussion

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    Discussing DNR Status

    Establishing DNR status is but one example of advance care planning. When undertaking to establish DNR status, the physician may want to consider a range of scenarios, not just the one that appears to be the most pressing. This may also give the discussion a greater sense of proportion

    • Establish general goals before discussing specific treatments
    • Confirm patient and family understanding about the medical condition and the context
    • Use understandable language
    • Avoid implying the impossible is possible
    • Ask about other life-prolonging therapies
    • Affirm what you will be doing
      Example of Possible Language for Discussion
      During the discussion, use language that is understandable, such as, "If you should die in spite of our current therapy, do you want us to use ‘heroic measures’? To do CPR? To press on your chest and put a tube in your lungs to try to get your heart and breathing started again?" To a layman, when the heart and/or lungs stop, the patient dies. It may be helpful to use the word "death" to clarify that CPR is a treatment that tries to temporarily stop death from occurring. If the patient (or parent if the patient is a child) wants more information, move to specific descriptions of what is involved with CPR after the more general question is answered
      The convention of initially discussing CPR as "starting the heart" or "putting on a breathing machine" implies a false sense of reversibility, or suggests those heart and lung functions are isolated problems. Avoid implying that the impossible is possible. In discussing DNR status with a patient with a life-threatening illness, avoid introducing CPR as "shocking the heart if it stops, using a breathing machine if the lungs stop." This reductionist approach fails to acknowledge the context in which CPR would be administered—to a patient who is dying of a disease. In the setting of advanced illness, circulation and breathing stop because of the relentless progression of the disease. If there were something to reverse, the medical team would do so long before the patient stopped breathing
      Further, avoid describing CPR as "doing everything." It implies that not doing CPR is "doing nothing." The issue of abandonment is implicit in discussions of CPR and DNR
      As part of the discussion, ask about other life-prolonging therapies. Put the discussion of resuscitation into the context of the host of life-prolonging therapies that need to be decided upon, including elective intubation and mechanical ventilation, dialysis, surgery, antibiotics, artificial fluids, etc. Consider describing various scenarios and eliciting the patient’s preferences. Avoid "getting the DNR" and leaving the patient
      Before ending the discussion, affirm what you will be doing for the patient. Confirm the active interventions that are or will be done for the patient. For many patients, full medical interventions to reverse disease and sustain life are appropriate even with a DNR order in place. However, if the patient dies in spite of all efforts, resuscitation will not be attempted
      So-called "slow codes" or "chemical-only" codes are unacceptable approaches to the issue of whether or not to offer emergency attempts to restore airway, breathing, and circulation. Their use promotes cynical approaches to decision-making and hypocritical interactions between physicians and patients

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    Write Appropriate Orders in the Medical Record

    • DNR
      • CPR involves the establishment of a patent airway, effective breathing, and cardiac output through assisted ventilation and external cardiac massage

      • If this is not appropriate or desired by the patient, the physician should write a DNR (do not resuscitate) order

      • A DNR order does not address any aspect of care other than preventing the use of CPR

      • Some institutions prefer a DNAR (do not attempt resuscitation) to avoid the implication of success that DNR connotes
    • DNI
      • A DNI (do not intubate) order is sometimes used for patients who do not ever want a ventilator used, even if the machine could save their lives

      • For example, patients with chronic or progressive lung diseases may choose an isolated DNI order

      • Patients who choose to have a DNR order have implied a DNI order, as CPR requires the establishment of airway, breathing, and circulation
    • Do not transfer
      • Some long-term care institutions may permit a "do not transfer" order to indicate preferences not to be transferred to an acute hospital setting, in the event of clinical decline
    • Others
      • Include all positive orders that relate to symptom control and those that guide intensity of care

      • Some institutions have special forms to facilitate communication and document orders
    • POLST
      • Physician Orders for Life-Sustaining Treatment, which is being used extensively in Oregon
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