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DNR Orders, Death Pronouncement and Notification


DNR Orders, Death Pronouncement and Notification Matthew S. Ellman, MD ICM, March, 2010 Content How to talk with patients about DNR orders How to do death ... – PowerPoint PPT presentation

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Title: DNR Orders, Death Pronouncement and Notification

DNR Orders, Death Pronouncement and Notification
  • Matthew S. Ellman, MD
  • ICM,
  • March, 2010

  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 dont treat
  • Named proxy means pt loses control
  • Only old people need advance directives.

Advance Directives/DNR discussions Hospital
  • Start with goals of care and clinical scenario.
  • Perfunctory vs. life-threatening condition

  • 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
  • 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/c10
  • 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

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 Id 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
  • Get the patient talking
  • If understanding inaccurate-- now is time to

What does the patient expect?
  • Ask/listen
  • What do you expect in the future?,
  • What goals do you have for the time you have
  • If unrealistic, clarify
  • Ask pt. to explain values underlying preferences.
  • Clarify/confirm
  • E.g. So what youve 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
  • 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
  • Malignant ascites, pleural effusion, bowel
    obstruction lt 6months.

Discuss DNR order
  • Use language patient understands
  • Dont 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
  • We have agreed that the goals of care are to
    keep you comfortablewith 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
  • Do not use DNR as proxy for other treatments
  • We will continue maximal medical therapy to meet
    you goals, however if you die, we wont 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

  • 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
  • Examining patient to determine death
  • Record proper documentation
  • 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

Coroners/M.E. Reportable Case
  • If patient in hospital lt24 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
  • Daughters 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 Im 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
  • 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

  • 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 dont ask
  • 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)
  • 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-

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
  • No notification to minors

Telephone Notification What to say
  • Buckman giving bad news
  • Prepare
  • What does patient know
  • (What does patient want to know)
  • Share the news (warning shot)
  • Respond to emotion
  • 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 Im sorry, ----- has just
    died. (not expired, passed away, didnt
    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

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