Open to Interpretation: Do Not ______

The Gist:  DNR (Do Not Resuscitate) orders are subject to variable interpretation by providers and patients whereas Physician Orders for Life Sustaining Treatments (POLST) are becoming increasingly common and have more specific, meaningful directives. As critical care providers, we should understand the meanings behind each of these documents, as well as the limitations.  The Annals of Emergency Medicine August 2014 podcast has a fantastic Free Open Access Medical education (FOAM) discussion of DNRs and POLSTs as they pertain to the physician in the Emergency Department (ED).  Despite these helpful aids, nothing replaces discussions with patients and their family members or health care proxies about treatment that is clinically appropriate and congruent with the patient's goals.

The Case:  A 82 y/o male presents to Janus General in respiratory distress, 72% on 4L of oxygen via nasal cannula up to 92% on 15L non-rebreather from the rehab facility where he is recuperating from a fractured tibia.  Previously in excellent health, he has been febrile and confused for the past two days with radiographic and clinical diagnosis of pneumonia and therapy with azithromycin and ceftriaxone at the facility.  Patient has a signed DNR order and an advance directive stating that for an irreversible/terminal condition the patient would not want artificial support.  The health care proxy is unavailable by phone and the patient lacks a clear sensorium but is in respiratory distress, appears septic, and has a chest x-ray with clear infiltrate and interstitial pattern that may indicate early ALI/ARDS.

• What should happen?  BiPAP?  Morphine? Intubation?  What's this patient's disposition?  At Janus General, the providers in the ED and the inpatient team disagreed about what the patient's course should be, whether or not the condition was "reversible," and what the patient would want in this situation.  

In a recent post I shared a talk on tips for palliative care in the ED setting.  Despite our best efforts in the ED, uncovering documents such as DNRs and advance care directives may obscure the picture more than provide clarity.  I discovered on rotations through critical care units that the presence of a DNR seemed to bias both myself and my colleagues regarding the care of patients that was unrelated to the performance of cardiopulmonary resuscitation.  I believe we acted based on what we felt was clinically appropriate in the patient's situation but upon closer inspection, I think we were occasionally subject to a touch of another form of bias - The DNR bias.

The Do Not Resuscitate (DNR):  A medical order that specifies one not initiate cardiopulmonary resuscitation (CPR) in a patient who has died (pulseless/apneic) [1].

• Technically, applies to a dead patient.
• Does not indicate a patient's general wishes for medical care, only their preference regarding initiation of CPR. 

The Problem With The DNR

DNR orders, which technically only speak to a patient's wishes to receive CPR, have variable interpretations amongst healthcare professionals and, likely, patients [2-4].  The issue lies in the word "resuscitate," which may be used to include fluids, antibiotics, vasopressors, advanced means of ventilation or, at the extreme, CPR.

• The TRIAD II-IV studies surveyed EMS personnel, physicians, and medical students respectively and provided the participants with an advance care directive as well as case scenarios.  The participants then indicated whether a patient was a DNR or full code and the appropriate action.  Both physicians and EMS providers performed poorly and variably, indicating that the directives were not clear [2,4].

DNR orders may mean that patients receive care that differs from their wishes or standard medical practice.  This demonstrates that the DNR bias may exist, even if it's partially a reflection of a patient's general clinical situation.

• Aspirin is a non-intensive and relatively safe standard intervention in patients with acute myocardial infarction (AMI) (NNT=42, NNH=167). In patients with an AMI, the Worcester Heart Attack study demonstrated a negative association between aspirin administration and those patients with a DNR [5].  Of note, the individuals in this study with a DNR were "sicker," meaning they had comorbidities or other poor prognostic signs such as shock.  Other markers of more aggressive care such as PCI, thrombolytics, and cardiac catheterization, were also reduced in the DNR cohort.  Therefore, it is possible that this association may represent the belief that these patients were not candidates for these interventions independent of their DNR status.
• The Worcester Heart Failure study also demonstrated that patients with a DNR were less likely to receive any quality assurance intervention than those with no DNR (HR 0.52, adjusted HR 0.63- 0.4-0.99) [7].  This may have been appropriate given the clinical situation of the patients.

But, it's not all about the co-morbidities:

• Residents in Missouri nursing homes with a DNR were less likely to be hospitalized following a LRTI (OR 0.69; 0.49-0.97).  Compared with the Worcester Heart Attack study, patients with comorbidities were more likely to receive aggressive treatment (hospitalization) than those without a DNR (excluded patients with a Do Not Hospitalize order) [7].  

The Physician Order for Life Sustaining Treatment (POLST) - Physician orders, on a standardized form, that are designed to transfer amongst settings, following an individual from home to hospital and nursing home/rehabilitation facilities.  Most states have POLST programs or are in the process of developing them these programs (map of programs) and some have online registries for providers, mitigating issues with located print copies.  Jesus et al give a good rundown of POLSTs in the ED in Annals of Emergency Medicine, August 2014 [8].

These may be more meaningful in the critical setting of the ED as they may indicate a patient's preference for a broad array of clinical conditions encountered.  For example, in Massachusetts, the back portion of the MOLST resembles a sushi menu where individuals can opt to specify whether they would accept non-invasive ventilation, dialysis, artificial hydration or nutrition and, if yes, whether temporarily or permanently.

Issues with POLSTs:

• Require a physician signature and require either medical literacy or a good deal of physician explanation.  
• It is possible that only the sickest patients or those with terminal illnesses may be prompted to have a POLST.
• Components are still open to interpretation by providers as the reversibility or predicted length of therapy are often difficult to determine upon initiation.  
• The FOAM blog, GeriPal, has an interesting discussion on the semantics prevalent in the POLST.  For example, the connotation of the word "only" following Comfort Measures is not necessary and undermines the intensive work often required for end of life comfort.  The blog offers some suggestions that may surface as POLSTs become increasingly adopted.

References:
1. Dugdale DC. .Do Not Resuscitate Orders."  MedlinePlus Medical Encyclopedia.  
2.  Mirarchi FL, Kalantzis S, Hunter D, McCracken E, Kisiel T. TRIAD II: do living wills have an impact on pre-hospital lifesaving care? J Emerg Med. 2009;36(2):105–15. doi:10.1016/j.jemermed.2008.10.003.
3. Mirarchi FL, Costello E, Puller J, Cooney T, Kottkamp N. TRIAD III: nationwide assessment of living wills and do not resuscitate orders. J Emerg Med. 2012;42(5):511–20. doi:10.1016/j.jemermed.2011.07.015.
4.Mirarchi FL, Ray M, Cooney T.  TRIAD IV: Nationwide Survey of Medical Students' Understanding of Living Wills and DNR Orders. J Patient Saf. 2014 Feb 27. 
5. Gurwitz JH, Lessard DM, Bedell SE, Gore JM. Do-Not-Resuscitate Orders in Patients Hospitalized With Acute Myocardial Infarction. 2014;164.
6. Chen JLT, Sosnov J, Lessard D, Goldberg RJ. Impact of do-not-resuscitation orders on quality of care performance measures in patients hospitalized with acute heart failure. Am Heart J. 2008;156(1):78–84. doi: 10.1016/j.ahj.2008.01.030.4. 10.1002/jhm.2234
7. Zweig SC, Kruse RL, Binder EF, Szafara KL, Mehr DR. Effect of do-not-resuscitate orders on hospitalization of nursing home residents evaluated for lower respiratory infections. J Am Geriatr Soc. 2004;52(1):51–8. 
8. Jesus JE, Geiderman JM, Venkat A, et al. Physician Orders for Life-Sustaining Treatment and Emergency Medicine: Ethical Considerations, Legal Issues, and Emerging Trends. Ann Emerg Med. 2014;64(2):140–144. doi:10.1016/j.annemergmed.2014.03.014.

CRITICAL Care - End of Life in the ED

The Gist: Palliative care is an emerging field in Emergency Medicine and most of us are inadequately equipped to discuss end of life issues, death and dying, which are all quite common in the Emergency Department (ED) [1].  We often feel uncomfortable in these situations as our instinct remains - resuscitate first, ask questions later. In a community that values cutting edge, critical care medicine, I was stunned when I realized that Free Open Access Medical education (FOAM) has engendered me to think twice about a procedure and take the time to ascertain what a patient actually wants.

These FOAM resources changed my course as a budding Emergency Physician and made me realize how ill equipped I was to handle dying patients, despite the frequency with which I encounter them.  As such, I felt compelled to use my slot at our residency conference dedicated to critical care to discuss end of life issues with my colleagues.  Here it is as FOAM, since I hassle others to share their talks.

CRITICAL Care - End of Life in the ED from Lauren Westafer on Vimeo.

The FOAM

SMACC GOLD (iTunes)

• Plenary "What is possible, What is reasonable, What is best?"
• Liz Crowe "Swearing Your Way Out of a Crisis."  This light hearted and absolutely hilarious talk gets at the difficulties of working surrounded by death and that there is still room for humanity and optimism - despite the cynicism popular in medicine. 
• Greg Kelly "When Children Die"

EMCrit with Dr. Ashley Shreves "Critical Care Palliation"

Boring EM - An Approach to Palliative Care in the ED

The Geripal Blog - The Importance of Language

The Take Home

Run these ABCD's in tandem with our typical ABCs (Airway, Breathing, Circulation) because the trajectory that we launch patients on matters - whether it's to the ICU with an endotracheal tube, to dialysis with a line, or a palliative care consult [1, 6-9,15].

Advance Care Directives (does the patient have one?), Ask the patient/caregivers what they want.

• Identify if a patient has a health care proxy or physician order for life sustaining treatment (POLST).  
• Use appropriate language, avoid jargon.  The phrase, "Do Not Resuscitate (DNR)," is falling out of favor and major societies are now using the language "Allow Natural Death"[3]. Try replacing DNR with "It sounds like she would want a natural death."  
• Dying patients, even those with DNR orders, Comfort Measure Only orders, or those with Do Not Hospitalize directives come to the hospital because dying is hard, uncomfortable, and stressful.  Figure out what they want and need, it's not always a tube or a line.

Better - Make the patient feel better

• Turn off monitors or beeping pumps (especially if they're beeping), generously dole out opioids for dyspnea/pain, offer various means of respiratory relief (non-rebreather, nasal cannula, non-invasive ventilation).

Caregivers - identify the patient's caregivers and Communicate with all parties in appropriate language

• As above, use appropriate language, avoid jargon.  My favorite phrase, effective on nearly all patients, "What is most important right now?"

Decisions - offer medically appropriate decisions in ways patients and caregivers can understand.  Aggressive resuscitation and cardiopulmonary resuscitation (CPR) are appropriate in many situations, but not all.  Think about the downstream consequences, positive and negative, of various courses of action.

• The publics perception of CPR is largely misinformed and studies show that most people overestimate the success of CPR to hospital discharge.  One study of patients over 70 years of age found over half believed survival after CPR was >50% and 23% believed survival to discharge was >90% after CPR [2].  Furthermore, people may not understand that CPR does reverse the underlying process and a patient is typically sicker after CPR than they were before.  Let patients know the implications of these decisions.  For example, once someone dies, CPR involves chest compressions which often result in broken ribs but sometimes restart the heart.  There's no guarantee that if we restart the heart that we will get his/her brain function back.
• If appropriate, offer more than one option and recognize the power and responsibility that comes with the entrusted title of physician.  People do listen to provider recommendations [5].  For example, some patients may want aggressive testing and treatment for etiologies of dyspnea, some may want oral antibiotics for a pneumonia if it may improve their shortness of breath, and some may opt solely for opioids. 

References:
1. Members of the Emergency Medicine Practice Committee.  Emergency Department Palliative Care Information Paper June 2012.   ACEP 
2. Adams DH, Snedden DP. How misconceptions among elderly patients regarding survival outcomes of inpatient cardiopulmonary resuscitation affect do-not-resuscitate orders. J Am Osteopath Assoc. 2006;106(7):402–4. 
3. Breault JL. DNR, DNAR, or AND? Is Language Important? Ochsner J. 2011;11(4):302–6. 
4. Cassel JB, Kerr K, Pantilat S, Smith TJ. Palliative care consultation and hospital length of stay. J Palliat Med. 2010;13(6):761–7. doi:10.1089/jpm.2009.0379.
5. Cook D, Rocker G. Dying with Dignity in the Intensive Care Unit. N Engl J Med. 2014;370(26):2506–2514. doi:10.1056/NEJMra1208795.
6. DeVader TE, Albrecht R, Reiter M. Initiating palliative care in the emergency department. J Emerg Med. 2012;43(5):803–10. doi:10.1016/j.jemermed.2010.11.035.
7. DeVader TE, Jeanmonod R. The effect of education in hospice and palliative care on emergency medicine residents’ knowledge and referral patterns. J Palliat Med. 2012;15(5):510–5. doi:10.1089/jpm.2011.0381.
8. Lamba S, Mosenthal AC. Hospice and palliative medicine: a novel subspecialty of emergency medicine. J Emerg Med. 2012;43(5):849–53. doi:10.1016/j.jemermed.2010.04.010.
9. Lamba S, Quest TE. Hospice care and the emergency department: rules, regulations, and referrals. Ann Emerg Med. 2011;57(3):282–90. doi:10.1016/j.annemergmed.2010.06.569.
10. Schmidt TA, Zive D, Fromme EK, Cook JNB, Tolle SW. Physician orders for life-sustaining treatment (POLST): lessons learned from analysis of the Oregon POLST Registry. Resuscitation. 2014;85(4):480–5. doi:10.1016/j.resuscitation.2013.11.027.
11. Wright A a, Keating NL, Balboni T a, Matulonis U a, Block SD, Prigerson HG. Place of death: correlations with quality of life of patients with cancer and predictors of bereaved caregivers’ mental health. J Clin Oncol. 2010;28(29):4457–64. doi:10.1200/JCO.2009.26.3863.
12. Wu FM, Newman JM, Lasher A, Brody A a. Effects of initiating palliative care consultation in the emergency department on inpatient length of stay. J Palliat Med. 2013;16(11):1362–7. doi:10.1089/jpm.2012.0352.