Resuscitation Orders: Upcoming Policy Changes
Key Point: The revised policy clarifies that the responsibility for decisions about code status is shared between clinicians and patients or surrogate decision-makers. “A patient (or authorized surrogate) has the right to agree to or • refuse offered resuscitative interventions or other life-sustaining treatments. The Health Care Team should not offer or provide interventions that are outside the boundaries of accepted clinical practice.” “Patients (or their authorized surrogates) will be involved in • decision making regarding all aspects of their care, including the decision whether to forgo (withhold or withdraw) resuscitative interventions or other life- sustaining treatments.” “Decisions about whether resuscitation will be withheld in the • event of a patient’s cardiac or respiratory arrest are reflected in two types of medical orders, a Do Not Attempt Resuscitation (DNAR) and a Virginia Durable Do Not Resuscitate Order (DDNR).”
Implications Patients and surrogates should • Shared Decision-Making Model be involved in care decisions, including decisions about code status. Clinicians have a responsibility • to provide care that benefits patients and to avoid causing harm. Sometimes CPR does not • provide benefit to the patient and/or may cause harm. Clinicians should not offer CPR if Graphic adapted from Nelson, K. E. & Mahant, S. (2014). Pediatric Clinics of North America, 61, 641-652. it is outside the bounds of accepted clinical practice.
The decision that resuscitation will not be attempted is reflected in 2 types of orders: Do Not Attempt Resuscitation (DNAR) and Durable Do Not Resuscitate (DDNR). DNAR DDNR Replaces DNR Medical order to • • withhold resuscitation In-hospital • used out-of-hospital Three levels that reflect • Must be converted to an • overall goals of EPIC order when patient care(details to follow) is admitted **The option of “Partial Code” is no longer available, except for during procedures.**
Key Point: The revised policy emphasizes the importance of a team approach. Although LIPs are responsible for code status orders, resuscitation efforts affect the whole team. The revised policy includes discussion between the patient/surrogate and the health care TEAM: “Prospective discussion regarding whether to forgo resuscitative • interventions as part of the patient’s goal -directed plan of care shall be held with the patient (or authorized surrogate) and the Health Care Team and documented in a progress note. The discussion shall address patient/surrogate preferences, goals of care, the contents of an advance directive (if such a document is available), and LIP /Health Care Team considerations, including the Attending Physician’s perspective.”
Implications LIPs discussing resuscitation options with patients/surrogates • will also discuss resuscitation status with other members of the health care team “Health Care Team” is defined by policy as: • Attending physician – Other LIPs, nurses, and respiratory therapists currently involved in – the patient’s care Other professionals not specified in policy, but should be included as – appropriate (Social Work, chaplaincy, etc.)
Key Point: The revised policy includes a focus on overall goals of care. DNAR orders will have an associated level of treatment that reflects these goals. ALL LEVELS: “If the patient has a cardiac or respiratory arrest, resuscitative efforts (as defined by the current published protocols of American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care) will not be undertaken in any form.” DNAR-A: All Therapy, But Do Not Attempt Resuscitation • – All medically appropriate treatment will be initiated to prevent cardiac or respiratory arrest DNAR-B: Non-Escalation of Therapy, Continue Current • Interventions, and Do Not Attempt Resuscitation – Continue current therapies, but do not add therapies unless the therapy promotes comfort DNAR-C: Comfort Measures Only, Do Not Attempt Resuscitation • – Treatment is limited to therapies focused on hygiene and comfort **Examples follow.**
DNAR A: All Therapy, But Do Not Attempt Resuscitation Mrs. S, a 72 yo female with CAD, HTN, and DM, is • admitted for heart failure exacerbation. She has decisional capacity, but is very short of breath. A discussion is held between Mrs. S, her family, and • the care team. Based on that discussion, the following goals are established: – Maximal treatment to support goals of getting out of the hospital BUT no CPR in the event of cardiac or pulmonary arrest The team places an order for DNAR A: All Therapy, • But Do Not Attempt Resuscitation
DNAR A: All Therapy, But Do Not Attempt Resuscitation What does this look like? • – If Mrs. S develops cardiac arrest, no attempts will be made to resuscitate her. – Mrs. S will receive vasopressors, admission to the ICU, and all other treatments up until the point of cardiac or respiratory arrest. These interventions may include intubation for pulmonary support. Note: DNAR A does not automatically exclude • intubation and mechanical ventilation EXCEPT in the case of cardiac or respiratory arrest.
DNAR B: Non-Escalation of Therapy, Continue Current Interventions, and Do Not Attempt Resuscitation Mr. B, a 52 yo male, was admitted to the MICU for respiratory failure due • to long-standing pulmonary disease. He has been in the MICU for 63 days, and has developed multiple complications including sepsis and renal failure, and is currently on norepinephrine, mechanical ventilation, and CRRT. He lacks decisional capacity and does not have an AMD. His daughter Bethany is his surrogate decision-maker. Bethany has struggled with her father’s illness. When approached about • goals of care in the setting of his worsening condition, she ultimately reaches consensus with the team to continue current therapies, but not add anything additional. Her fiancé is flying in tomorrow, and she wants to wait for him to arrive before any additional discussion. The team places an order for DNAR B: Non-Escalation of Therapy, • Continue Current Interventions, and Do Not Attempt Resuscitation
DNAR B: Non-Escalation of Therapy, Continue Current Interventions, and Do Not Attempt Resuscitation What does this look like? • – Mr. B will remain on mechanical ventilation, his current dose of norepinephrine, and CRRT. – These therapies will not be escalated, and no additional therapies (i.e. another vasopressor) will be added unless they are added to achieve a specific goal (for example, it may sometimes be appropriate to increase vasopressors to allow family time to arrive at the bedside). – Therapies may be added to promote comfort and dignity.
DNAR C: Comfort Measures Only, Do Not Attempt Resuscitation Mr. H, an 82 yo male, was transferred from an outside hospital • with a large intracranial hemorrhage. He is unconscious on the ventilator but is hemodynamically stable. He doesn’t have an AMD. A goals of care discussion is held with his family, including his wife • and children. Based on Mr. H’s values, beliefs, and previously expressed preferences, the decision is made to withdraw aggressive therapies and provide only those interventions that promote comfort. The team places an order for DNAR C: Comfort Measures Only, Do • Not Attempt Resuscitation.
DNAR C: Comfort Measures Only, Do Not Attempt Resuscitation What does this look like? • – Support is provided to the family, and measures are taken to promote Mr. H’s comfort and dignity. – The ventilator and any other interventions that do not support comfort are stopped. – No resuscitation will be attempted in the event of a cardiac or respiratory arrest. – Treatments that are necessary for comfort should be used, even if they inadvertently result in respiratory or cardiac depression.
Key Point: Required documentation of code status in EPIC includes 1) a code status note, and 2) a code status order. Note (template will be available) Code Status Orders will • • show up in the EPIC Order (LIPs chooses one of the • banner, as follows: available options from Code Status Order Panel): – Full Full code – DNAR-A – DNAR-A: All therapy, but do not – – DNAR-B attempt resuscitation – DNAR-C DNAR-B: Non-escalation of – – Full for Procedure therapy, continue current interventions, and do not attempt – Partial for Procedure Resuscitation DNAR-C: Comfort measures only – For Procedure Only, Full Code – For Procedure Only, Partial Code –
Key Point: Ethics Consultation is required if conflicts arise between the team, patient, and/or family, and cannot be resolved by the healthcare team. “ If conflicts develop over the appropriateness or • interpretation of a DNAR Order or a DDNR Order and the healthcare team is unable to resolve such differences, the Ethics Consultation Service will be consulted to clarify ethical issues or mediate conflicts.”
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