American Journal of Critical Care. 2003;12: 239-241
CE Online
Do-Not-Resuscitate and Stratification-of-Care Forms in Rhode Island
By
Vera A. DePalo, MD,
Rhonda Iacobucci, RN, MS and
Robert S. Crausman, MD, MMS.
From
Brown University School of Medicine, Providence, RI.
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Abstract
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Congress passed the Patient Self-Determination Act of 1990 to ensure that patients are informed of their rights to express healthcare preferences in advance of loss of capacity. Thus, a patient may elect to forgo cardiopulmonary resuscitation in favor of a treatment approach that favors comfort over survival. Do-not-resuscitate and stratification-of-care forms provide a means for expression of healthcare preferences in hospitals. These forms can often guide the important discussion of healthcare preferences. Unfortunately, no clear standard exists for what should be included in do-not-resuscitate or stratification-of-care forms that institutions seeking to improve in this vital area of practice could use for guidance. Existing forms in use at adult general hospitals throughout Rhode Island were reviewed.
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Perhaps the most important advance in contemporary medical ethics of the last generation was the increased focus on the role of a patient’s autonomy in values-based medical decision making.1,2 As an underscore to this, Congress passed the Patient Self-Determination Act of 1990 to ensure that patients are informed of their rights to state their healthcare preferences and to execute advance directives at the time of admission to hospitals, home care agencies, managed care organizations, and nursing homes.3,4 Thus, in complex medical decision making, particularly in matters of life or death, the patient’s wishes are of paramount importance. A patient may elect to forgo cardiopulmonary resuscitation in favor of an approach that favors comfort over survival. An advance directive allows a person to clarify choices for treatment or designate a proxy decision maker in the event that decision-making capacity is lost. The discussion outlining a patient’s wishes is often difficult for patients, their families, and physicians.
In order to provide a vehicle for expression of healthcare preferences in the hospital, a proliferation of documents that are often simply labeled do-not-resuscitate forms has occurred. More encompassing forms attempt to outline preferences for the stratification of care in critical situations that do not involve cardiopulmonary arrest. These forms can serve as a foundation for the discussion necessary to gain a better appreciation of a patient’s wishes. Unfortunately, unlike the healthcare proxy, living will, or durable power of attorney for healthcare, no clear standard exists. As our hospital’s ethics committee endeavored to improve the alignment of implementation of aggressive therapies with patients’ preferences, we reviewed corresponding documents in use at adult general hospitals throughout our state, Rhode Island. Here we report our findings.
 Do-not-resuscitate forms are not standardized and may document patients’ wishes about cardiopulmonary resuscitation only or may include a wide range of care options.
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| Forms used in 8 Rhode Island hospitals were reviewed and described.
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Methods
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Stratification-of-care forms in use at the 7 major general hospitals for adults and 1 hospital for women and infants were reviewed by 2 critical care physicians (RSC, VAD) and 1 critical care nurse (RI) and described. From these descriptions, a clear categorization emerged, and forms were subsequently grouped as being either limited or extensive. Relative strengths and weaknesses of the various approaches are described.
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Results
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Stratification-of-care forms from the 8 hospitals could be divided into 2 distinct subgroupings. Three hospitals offered an extensive menu of choices for therapeutic options when patients were in cardiopulmonary arrest and when patients were not in cardiopulmonary arrest (the "extensive" group). One hospital in this group was a teaching hospital. The second group (n = 5) had do-not-resuscitate forms that were more limited in scope (the "limited" group). Three hospitals in this group were teaching hospitals. Summary results are presented in Tables 1
and 2.
As a minimal standard, all hospitals had forms that provided for establishing a do-not-resuscitate order. Half allowed for distinction between cardiopulmonary resuscitation, administration of vasoactive medications, and electrical therapies. Five specifically delineated mechanical ventilation, 3 addressed the use of antiarrhythmic medications, and 3 addressed the use of temporary pacing. None drew a distinction between transvenous and transcutaneous pacing. Only 3 hospitals documented the basis for decisions limiting resuscitation: 2 called for specific designation of a surrogate decision maker and 1 for regular periodic renewal.
In situations that did not involve cardiopulmonary arrest, forms from most hospitals delineated nutrition, hydration, blood products, laboratory testing, and dialysis. Four specified antibiotics and transfer of the patient to the intensive care unit. Two specifically provided for limitation of respiratory treatments.
Mechanical ventilation was specified in 2. Only 1 hospital’s forms addressed time-limited ventilatory support, and none distinguished between invasive and noninvasive ventilation.
No form referenced a patient’s wishes concerning hospice care, palliative care, or organ donation.
| Care options included on do-not-resuscitate forms varied across all settings; most were limited in scope. Most forms included options for intubation, nutrition, hydration, and use of blood products, but none included options for noninvasive ventilation or organ donation.
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Discussion
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In the past, treatment choices often were made for patients by physicians or by the patients’ families. Patients’ preferences are being incorporated into aggressive and end-of-life care more frequently. Many of these discussions about treatment choices, however, still occur during acute care. Do-not-resuscitate and stratification-of-care forms are working documents that can inform staff members, in the event of critical illness or arrest, about patients’ wishes. Our review of the forms in use in Rhode Island uncovered a substantial variation in a small geographic region. This variation, although potentially confusing for health-care professionals who may provide care at more than a single site, is most likely compensated for by local familiarity with these forms and hospitals’ educational efforts.
Forms were of 2 types: limited and extensive. Teaching hospitals tended to have the limited form. The ubiquitous presence of house staff may factor into the choice. The assumption is often made that house staff, who would be present during a situation involving cardiopulmonary arrest, would have interacted more often with patients and would have a more complete knowledge of patients’ wishes. In our experience, house staff often do not have that level of knowledge of patients’ wishes. Also, with the cross-coverage patterns of attending physicians in teaching institutions, the attending physician who completes the form may not have the rapport that the patient’s own physician has and therefore might not feel comfortable with an extensive discussion.
A more extensive form may guide discussion to a better understanding of a patient’s wishes. The danger arises when the form is presented as a restaurant menu and a patient or surrogate makes choices that are contrary to the spirit of the patient’s wishes. This problem can be avoided by a discussion with goal orientation. The discussion would focus on the spirit of the patient’s wishes, and each possible therapeutic intervention could be discussed relative to its alignment with the goal.
Forms were generally phrased in the positive by designating treatments to be provided in situations that do or do not involve cardiopulmonary resuscitation. Those forms phrased in the negative, that is, forms that required delineation of therapies not to be given, were somewhat less clear. A form that uses yes versus no check boxes adjacent to each therapy would seem to be the least ambiguous. Neither the limited nor the extensive approaches appeared to be consistently superior in this regard.
Surprisingly, none of the forms reviewed in our statewide survey distinguished between invasive and noninvasive ventilation5 or between transvenous and transcutaneous cardiac pacing. Such distinctions would be important. Many patients seek to define how willing they would be to accept an invasive intervention. Not including a discussion of organ donation at the time of stratification of care seems to be a missed opportunity. Half of the forms reviewed separated aggressive treatments (eg, cardiopulmonary resuscitation, intubation, administration of vasoactive drugs, electrical therapies) from each other, creating a choice between no resuscitative effort and some combination of aggressive therapies, a choice that in many circumstances could markedly reduce the probability of successful resuscitation.
Although strong conflicting arguments can be made both for increased consistency across institutions and for preserving the freedom of individual institutions to use site-specific documents to meet local needs, it seems useful to share our experiences and develop common foundational principles. Because stratification-of-care forms are used in discussions with both patients and their families, and such forms are used by first responders in situations involving cardiopulmonary arrest, clarity and ease of review are of particular importance.
| Although do-not-resuscitate forms should reflect the needs of individual institutions, consistency across institutions may also be beneficial.
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Commentary by Mary Jo Grap (see shaded boxes).
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REFERENCES
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- Beauchamp T, Childress J. Principles of Biomedical Ethics. 4th ed. New York, NY: Oxford University Press; 1994:120–181.
- Crausman RS, Armstrong JD Jr. Ethically based medical decision making in the intensive care unit: residency teaching strategies. Crit Care Clin. 1996;12:71–84.[Medline]
- Omnibus Budget Reconciliation Act of 1990.(OBRA-90), Pub L No. 101–508, 4206 and 4751 (Medicare and Medicaid, respectively), 42 USC 1395cc(a) (I)(Q), 1395 mm (c)(8), 1395cc(f), 1396a(a)(57), 1396a(a)(58), and 1396a(w) (Supp 1991).
- Teno JM, Licks S, Lynn J, et al. Do advance directives provide instructions that direct care? SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. J Am Geriatr Soc. 1997;45:508–512.[Medline]
- Crausman RS. Patient-centered ventilation. Chest. 1998;113:844–845.[Free Full Text]
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Abstract
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