Avoiding the Pitfalls in CPR/DNR Decision Making

Avoiding the Pitfalls in CPR/DNR Decision Making

Educational Objectives:
Examine the obstacles to good DNR decision making.
Discuss what is CPR and the perceived vs. actual chance for success.
Demonstrate best practices for communicating about CPR.
Consider how the signing of the DNR is just one component of
end-of-life care.

Background:
Older adults and their loved ones are being asked to make difficult end-of-life choices about CPR (cardiopulmonary resuscitation) and its refusal, DNR (do not resuscitate). These decisions are fraught with emotional angst and misinformation. In the past, we only used CPR on patients who were having a heart attack and who might benefit from receiving CPR. Now we use it for everyone, including those in a terminal state, whether it will work or not.

One of the complicating factors is that CPR used to be very simple to understand. Now, the general public doesn’t realize that when the doctor says CPR, she is including medications, intubation and ventilator support. A common misunderstanding occurs when people are given the misleading choice of a “chemical code only.” As nurses and doctors will tell you, if the doctor gives the medicine but doesn’t do the chest compressions to move the blood around, the medicine will not circulate in the body. Without circulation, the medicine can not do its job.

Another factor is that the decision about CPR has inappropriately become an indicator of a person’s complete end-of-life wishes—but the decision about CPR should be only one part of the treatment plan. A patient may want chemotherapy, surgery, radiation therapy or other kinds of aggressive treatments and still may want to be a DNR. Or the person may not want other medical treatments but still want to receive CPR. These are all separate decisions and any combination is possible.

One positive change is that the language of DNR has been modified to “do not attempt resuscitation” (DNAR) or “allow natural death” (AND). Both of these help to clarify the confusion. Do not attempt resuscitation truthfully explains that just because CPR is attempted, doesn’t mean it will work. If you ask healthcare professionals, “How many of you would like to die by CPR?” No one ever, ever raises a hand. What they know, but don’t always share with their patients, is that the chance of CPR working is minimal, sometimes even 0 percent. On television shows like ER, CPR brings the patient back to life about 75 percent of the time (Diem, Lantos and Tulsky 1996), when in real life it only works, at best, 17 percent of the time on healthy patients (Peberdy, et al. 2003). In many real-life situations, the chance of success is zero.

William J. Ehlenbach, MD, lead author of a study of CPR in the elderly, published in the New England Journal of Medicine in 2009, explains, “CPR has the highest likelihood of success when the heart is the reason, as in an ongoing heart attack or a heart rhythm disturbance. If you’re doing well otherwise, CPR will often be successful. But, if you’re in the ICU [intensive care unit] with a serious infection and multiple organ failure, it’s unlikely that CPR will save you” (quote from Gordon 2009; study published by Ehlenbach et al. 2009).

The newest term, allow natural death or AND, is a more gentle way of saying do not resuscitate. Instead of stating what won’t be done for the patient, the doctor is offering to allow the patient a peaceful, natural death and will not attempt resuscitation. Because the CPR/DNR decision is about more than medicine, it frames the dying experience for the patient and the loved ones. For those who are making the CPR/DNR decision, it is important to balance the chances of CPR working and bringing the person back in a good condition with the desire for a good, peaceful and dignified death. This is why healthcare professionals wouldn’t want to die by CPR; there is nothing peaceful or dignified about this type of death.

Case study 1:
Mr. Jackson is a 67 year old gentleman who has end-stage Alzheimer’s, is unable to eat and recently had a feeding tube placed. The patient does not have an advance directive and never told his kids what he would want done and unfortunately, his doctor didn’t ask about his CPR wishes when he was in the early stages of the disease. The physician is now asking, “Would he want CPR?” His adult children have been through a lot over the past years and are overwhelmed by the question. The thoughts running their minds are, “Is it time? Are we giving up? I don’t want to make this choice but I can’t stand watching him suffer any longer. If I make this decision, does that mean I have lost my faith?”

How can the healthcare team help guide the adult children through this decision making process? What are the underlying issues that will make the decision more difficult to make? What statistical information might make the decision easier? What grief support can the healthcare team provide to ease the process?

Discussion – Mr. Jackson:

How can we as aging professionals help those we serve as they struggle with these difficult decisions? One of my roles as a bioethicist is to assist families, like Mr. Jackson’s, who are making the difficult decisions. I am not there to tell the family or healthcare team what to do, but to help those involved to think through the issues so they can make a more informed decision. It is important during these conversations that we keep the patient’s wishes and needs at the forefront.

When working with Mr. Jackson’s son and daughter, I would make sure they are educated about CPR. Hopefully, Mr. Jackson’s doctors will not have eroded the trust and created a confrontational relationship by pushing for the DNR. I would need to be patient as these end-of-life conversations are a process, not a one-time event.

I would make sure Mr. Jackson’s children understand the possible outcomes of CPR. He may survive CPR but never be able to leave the hospital or he may be hooked up to ventilators for the rest of his life. Research has found if CPR is able to bring a patient back to life, the chance of the person going home with good brain function is about 7 percent (Kaldjian, et al. 2009). And in Mr. Jackson’s compromised condition, his chances are even lower. The typical success rate of CPR will depend on the health of the patient, the patient’s age, how quickly the CPR was begun and other medical factors.

Next, I would make sure that the family understood what can happen during CPR. Mr. Jackson may be brought back to life but in a worse condition than before, both mentally and physically. There is a chance of broken ribs, a collapsed lung, damage to the windpipe, and the longer he isn’t able to breathe, the greater the chance for brain damage.

Once the family understands the likely chance of CPR working and what kind of outcomes might be expected, I would then point out that by discussing that by choosing CPR, Mr. Jackson may not have the opportunity for a peaceful and meaningful death experience. I would ask his children, “When your father pictured the last minutes of his life, did he see strangers straddling him on a bed, pushing on his chest, with his family waiting outside his door? Or would your father want his family and friends gathered around his bedside, with words of love being expressed, music being played or prayers being said?” By asking these important questions, I am helping to contextualize the medical choices by explaining what it will be like for their father to experience CPR versus a more peaceful death.

Another common issue I may have to address is to relieve the guilt and angst of those making these difficult decisions. One gift I may be able to give Mr. Jackson’s children is to help them understand that it not really their decision. It is the patient’s decision. I would explain that as the decision makers, they are supposed to consider all that they know about their dad, what he has told them in the past, what his values are, and what would be important to him. Using this information, they should do their best to make the decision they think their father would make.

I would gently ask, “What would your dad be telling us if he were able to understand what has happened? What would your dad say about wanting CPR?” And then I would be quiet and let them sit with the question. In most situations, the family will know the answer but it will be painful for them to verbalize the choice. I would then acknowledge how loving and courageous they are to honor their father’s wishes. No matter what decisions are made, it will be important that this family receive emotional and spiritual support as they struggle with these issues.

Case Study 2:

Mrs. Garcia is an 83 year old woman who has multiple sclerosis. Her advance directive states that she does not want CPR. Her multiple sclerosis has developed to the stage where she has lost the capacity to speak for herself. Her husband is her decision maker and caregiver and he knows her wishes. Last week, Mrs. Garcia suffered a heart attack and is now in the ICU. This morning she coded and was brought back to life by CPR. Her husband has just been called to come to the hospital and was told that his wife survived CPR but her condition is deteriorating. What went wrong? Why wasn’t her DNR honored? What is Mrs. Garcia’s expected outcome after receiving CPR?

Discussion – Mrs. Garcia

What went wrong?

Unfortunately, this scenario happens more often than it should. When Mr. Garcia got the call about his wife, he was shocked and angered. How could this happen?

There are a few possibilities. Some doctors won’t agree to a DNR because of moral opposition and therefore won’t write or respect a DNR. While doctors are allowed to live by their morals and to refuse to participate in acts that go against their values, they are still obligated to let patients know about valid medical options and then let the patient or decision-maker decide. If the doctor is unwilling to do this, then the doctor should help the patient to find another doctor who is willing to talk about the DNR option. If the patient, family or someone from the healthcare team is worried about the patient’s rights being violated, he or she should call for a bioethics consult from the hospital’s bioethics committee.

Another possibility is that the DNR request from her Advance Directive was not transferred onto her hospital chart. If the DNR is not on the chart, it doesn’t exist. Whether you are the patient, the loved one or someone working with the family, make sure you go over the patient’s Advance Directive and other healthcare wishes with the doctor and make sure they are documented.

A final possibility is that medical miscommunication occurred. Perhaps the advance directive wasn’t sent up from the emergency room, the team couldn’t find the DNR, no one took the time to look for it, the on-call physician wasn’t familiar with the patient or numerous other mishaps. As much as the public would like medicine to be perfect, healthcare is significantly flawed and human.

What should happen next?

The first step will be to make sure the DNR order is written immediately. I would hope that apologies would come next. Administration, risk management and other hospital staff will be involved in resolving this situation. This event will be evaluated to determine what caused this medical error and to take steps to make sure it doesn’t happen again. (But it will happen again, but usually not to the same patient.)

Ultimately, the doctor will need to sit down and to talk about where to go from here. Since the CPR was performed, what condition is the patient in? What options are available which would be respectful of Mrs. Garcia’s wishes? Is it time for a hospice referral? The doctor who performed the CPR may not be the best person to handle the situation at this point because of the broken trust. It may be necessary to bring in a different consultant to help bring peace to this situation. It will also be important to address Mr. Garcia’s anger and frustration with the hospital and the healthcare team. He will probably be devastated that his wife’s wishes were not honored and that she is still suffering. Appropriate social services should be brought in to help him with his grief.

Upon evaluation of the event, it appears that it wasn’t that Mrs. Garcia’s wishes weren’t respected, but her wishes were not known (because no one read her advance directive) and the CPR/DNR conversation never occurred. This is also a common problem in healthcare. Many physicians are uncomfortable talking about end-of-life issues. I would hope that healthcare professionals don’t just talk about the medical choice of CPR but would also talk about what kind of life one would want after CPR and what kind of death is desired. The following questions are just as important as, “Do you want CPR?”

Where would the person want to die?
Whom would the person want to be with as he or she dies?
What would bring peace and comfort during the dying process?
For many people, CPR just prolongs the dying process, is this okay?

Conclusion:
The conversation about CPR and other end-of-life decisions is a journey of informing, understanding and helping to support the person who has the difficult choice to make. As professionals, we have to find the courage to walk with our patients as they move through their illness and toward death. As patients and family members, it is important to have these conversations early on and I would encourage everyone to ask for the answers and support you need. If the doctor won’t talk to you, find a doctor who will. And if after talking with the doctor, you realize he won’t respect or support the patient’s wishes, find a doctor who will. Once you have made the decision, write it down and tell others what you would want. Don’t make them guess.

A final thought: I am not saying that people shouldn’t choose to attempt CPR; I just want to make sure patients and their loved ones have the facts about what is CPR, the chance of it working, the kind of condition the person might be in after CPR and the kind of death that is being chosen. Make wise and informed decisions for yourself and for those in your care. Have a kind and respectful day.

Study Questions:
What are the common misunderstandings about CPR?
When talking about DNR, what other issues should be discussed?
What do you think would get in the way of you making a good decision for your loved one?
What decision would you make regarding CPR/DNR and how does that affect how you interact with those you serve?

References
Diem, S. J., J. D. Lantos, and J. A. Tulsky. 1996. Cardiopulmonary resuscitation on television: Miracles and misinformation. New England Journal of Medicine 334 (24): 1578–82.

Ehlenbach, W.J., A.E. Barnato, J.R. Curtis, et al. 2009. Epidemiologic
study of hospital cardiopulmonary resuscitation in the elderly.
New England Journal of Medicine 361 (1): 22–31.

Gordon, S. 2009. CPR Survival Rates for Older People Unchanged.
HealthDay: News for Healthier Living, July 1, 2009.
Kaldjian, L.C., Z.D. Erekson, T.H. Haberle, et al. 2009. Code status discussion and goals of care among hospitalized adults. Journal of
Medical Ethics 35 (6): 338–42.

Peberdy, M.A., W. Kaye, J.P. Ornato, et al. 2003. Cardiopulmonary
resuscitation of adults in the hospital: A report of 14,720 cardiac
arrests from the National Registry of Cardiopulmonary Resuscitation.
Resuscitation 58

Have a kind and respectful day.

DNR (do not resuscitate or no CPR) does not mean do not treat or do not care. A warning for all of us.

Dear Viki,

I noticed that after my dad became a DNR in the hospital, the nurses didn’t come into the room as often anymore and the doctor didn’t visit the way he used to. Just because my dad didn’t want to have CPR didn’t mean that he still didn’t want to fight his cancer. But it seemed like everybody gave up on him. Did the DNR (do not resuscitate) decision really mean, Do Not Care?

I realize that not only are patients confused about what DNR means (do not do CPR), but nurses and physicians are also confused. I know that’s not what you want to hear, but it’s true. Somehow DNR has become a decision about treatment choices instead of just CPR. What DNR should mean is only one thing, do not do cardiopulmonary resuscitation.

Research has found that if a patient is a DNR, then healthcare professionals may believe that the patient doesn’t want any other types of aggressive treatment. But this isn’t true. A patient may want chemotherapy, surgery, radiation therapy or other kinds of aggressive treatments, and still not want to receive CPR. A DNR doesn’t tell you anything about what other treatments the patient might or might not want to receive.

I’m not telling you this to scare you out of being a DNR. Not at all. I am just reminding all of us that one part of the end-of-life decision making process does not dictate everything else we might want. So yes, you can be a DNR and still have appropriate aggressive medical treatments. Or you can be a DNR and choose only to have hospice care. Or you can be on hospice and not be a DNR. Or you can choose some of the medical treatments being offered and refuse others. These are all separate decisions. You get to choose from all of the appropriate medical options available. Choose some, choose all or choose none. It is up to you. The only thing you can’t choose is a treatment that is not a valid medical option. You cannot make the doctor gave you ineffective or non-beneficial treatments. You are only allowed to choose from the list of medically appropriate treatments for your condition.

Lastly, as a reminder to all the healthcare professionals. A DNR never represents a do not care order. We should still be going into their hospital room as often as we would for someone without a DNR. We should always treat the patient with respect and dignity and provide comfort care to manage their suffering.

Have a kind and respectful day.

On Wednesday, May 4th, 8AM pst, blogtalkradio.com/kindethics, I will be interviewing Dr. Mark Apfel, “Having the POLST Conversation With Your Patients”

On Wednesday, May 4th, 8AM pst, blogtalkradio.com/kindethics, I will be interviewing Dr. Mark Apfel, “Having the POLST Conversation With Your Patients”

Dr. Mark Apfel is a physician champion working with the California Coalition for Compassionate Choices, finalchoices.org. He will be discussing how the POLST form will be helping physicians and patients. He will also be answering questions about how to use the form with your patients as well as how to discuss these end of life issues with your patients.

To listen or to call in dial (347) 945-5152. Or go to blogtalkradio.com/kindethics or go through the blogtalkradio link on the right side of my blog.

Have a kind and respectful day.

Why did the doctor do CPR against the patient’s will?

Dear Viki,

I just got the call that my father-in-law was resuscitated (got CPR) twice even though he had a DO NOT resuscitate order in place. Instead of a being allowed to die, now he is in the ICU and receiving care he doesn’t want. What just happened? What do I do next?

Even though this isn’t supposed to ever happen, it happens at all hospitals. A DNR or a do not resuscitate order should be followed but sometimes because people are in a hurry or don’t check the chart or don’t agree with the order, and the person is brought back to life against their will. This is a terrible thing for the patient and family to go through, Instead of the patient getting to die a natural death, they receive medical care against their will.

Here is the truth about this situation. If the medical professionals knew that there was a DNR in place, then what they did to your father-in-law is called assault and battery. The people involved can be arrested and criminally charged. And I need to let any healthcare professionals that might be reading know that your malpractice insurance won’t cover this because it is a criminal offense.

But what can you do now that it has happened. The best thing to do is to talk to the nurse and find out if they realize they made a mistake. (Don’t be hostile or aggressive as these caregivers are still taking care of your father-in-law.) Be polite and make sure that there really is a DNR written on the chart and that they will make sure it is respected. Sometimes we think these instructions have been written but the doctor hasn’t gotten around to it or won’t write it. There are some physicians that are morally opposed to the DNR and are supposed to tell you that they won’t do it. But many times they won’t tell you or even let you know it is a valid medical option. If the doctor won’t write the DNR, then fire that doctor and get another doctor to write it immediately.

You may also want to notify the hospital administrator who is on call. Let them know what has happened and they can help you. The other person that can help you is the social worker. The social worker will know who to call and will help advocate for the patient.

Another note: I spoke with this person directly and found out that the family thought that the patient had a DNR but really only had an advance directive that said do not resuscitate. Those wishes were not transferred onto the chart. This is something we need to be careful about. Just because the patient may have refused a certain treatment, it doesn’t really count until it is known by someone on the healthcare team. Of course the patient’s wishes should always be respected, but these are serious orders about life and death and they must be written out by the doctor. (It still might be assault and battery if the patient’s wishes in the advance directive were known by the healthcare professionals.) Make sure you go over your loved one’s advance directive doctor when you arrive at the hospital.

Why Won’t the Patient/Family Sign the DNR?

A couple of things may be going wrong. The first thing that happens is that the patient doesn’t understand the success rate of CPR.

On the television show “ER”, the patient not only survives CPR about 80% of the time but they also wake up with no negative consequences from the resuscitative efforts. We need to educate them that CPR works about 15-20% of the time on healthy people and less than 1% of the time for those with multi-system organ failure or metastatic cancer. We need to tell them that they may wake up in a worse condition than before and we need to tell them when it may only prolong their suffering and dying.

The second thing that goes wrong is that we limit our discussion to CPR. The CPR question should be one of many significant questions we ask during a meaningful end of life conversation. We need to ask them about how and where they would like to die.

Ask them, “How can I respect you and help you as you die?” We need to tell them that they have the choice of having a stranger straddling them doing compressions while their family waits outside the door or a peaceful death surrounded by their loved ones? I have never met a doctor who said they would choose the lonely CPR death, so why would you think your patients would want this?

The other thing most people want is to die at home but 53% die in hospitals and 24% in nursing homes. Please send people back home with hospice support.

One other thing you might try is you may want to begin using the term “AND” or Allow Natural Death when you talk about DNR. It is much easier to talk about what they would be allowing versus what you would be taking away from them. Just changing this language changes the discussion. This language also helps when you are talking to people from other cultures. It is difficult for families to choose to “give up” when what you are really offering is a good death.

No matter what, patients and families need us to talk about these scary and difficult subjects. We have to have courage to walk with them as they journey toward death.

Got a question? Ask Viki.

Helping the Family Make the Difficult Decisions

Doctors tell me all the time that they struggle with families that aren’t respecting the patient’s wishes or are not making wise decisions for their loved ones. Over the next months, I will give you many techniques you can use in these situations. Here are two to help you begin.

A dear friend of mine was sitting at the bedside of his wife after her massive stroke. They had been married for over 50 years. As I sat with him he said to me, “The doctors keep asking me what I want them to do. Well, what I want is for them to keep Ruth alive no matter what.” I nodded and listened as he continued. “If they asked me what Ruth would want, she would say, “Let me go, I don’t want to live like this. But the doctors don’t ask me what she wants, just what I want.” I was so surprised that in his grief he understood the difference.

So here are two techniques you can begin to use to improve end of life decision conversations. First, stop asking, “What do you want us to do?” And instead ask, “What would (the patient’s name) want us to? What would (the patient’s name) be telling us to do in this situation?” And if the family member responds, “What I want is …” you stop them and re-clarify that they are supposed to speak as if they are patient. You can always use the classic question, “If the patient was able to wake up for 5 minutes and understand what was going on, what would the patient say?” The trick is to keep silent after the question and let the family member struggle with the question. The silence in the room helps the person understand the significance and the weight of the question. Don’t rush them as they haven’t been thinking about what the patient would want; only what they would want.

Secondly, you need to educate the family about their role as the decision maker early on. Explain to them that they are supposed to make the decisions based on the patient’s values, not what they would want. Tell them that they are supposed to speak with the patient’s voice and wishes, even if it’s hard to do. I think we need to acknowledge how difficult this job is for the family member and to validate their struggles. “I know this must be very difficult for you, but it is important that we respect your loved one and follow their wishes.” If we can begin the conversation with the right questions and to educate families regarding their role, it will provide a good beginning to improving end of life communication. More to come on this topic later.

How Can the Doctor Ask Me to Kill My Mom?

The doctor just told you that you have difficult decisions to make. She said that you have to decide if it is time to let your mom die. Do you want us to take your mom off the ventilator? Would your mom want CPR? How can you decide? Well I have a gift for you. It is not your decision. It is your loved one’s decision. You are just the representative of the patient and are supposed to be speaking as if you were the patient themselves. You are supposed to use the values of the patient, not your values.

Here is where your mom’s doctor went wrong. The doctor should have asked, “What would your loved one be telling us if they were able to speak right now? What would your mom say about wanting CPR? Would your mom want to continue on like this? These are the right questions. But instead the doctor burdens us by making it seem like it is our choice. But it shouldn’t be our choice. We are the surrogate decision maker, the substitute just filling in for the patient. Different states call it different things: durable power of attorney, agent, proxy or surrogate. But no matter what we call it, the rules are the same. You are supposed to honor the patient’s wishes,

I know the doctors never told you this before. But let me explain how it works, it is something called the substituted judgment standard. We are supposed to speak with the voice of the patient. As the decision maker, you are supposed to think about everything you know about the patient, what they have told you in the past, what their values are and what is important to them. Then using this information, do your best to make the decision you think they would make.

What if after considering all of this, you realize your mom would say, “I don’t want to live like this, I would rather die.” Then you have to tell the doctor the truth. I can hear you saying, “But I don’t want her to die.” Of course you don’t. But you have a job to do and it is up to you to be brave. You need to do the respectful and loving thing and tell the doctor what she would say even if it is not what you would choose yourself. This is the gift you can give your loved one by speaking for them one more time. Otherwise you are betraying your loved one and disrespecting their beliefs and their life. I am not saying this is easy to do, but it is the right thing to do. And usually doing the right thing is doing the hardest thing.