Development of a statewide protocol for the prehospital identification of DNR patients in Connecticut including new DNR regulations

Emergency department DNR order in patients with spontaneous intracerebral hemorrhage

OBJECTIVES

To explore the determinant factors and prognostic significance of emergency department do-not-resuscitate (ED-DNR) orders for patients with spontaneous intracerebral hemorrhage (SICH).

METHODS

Consecutive adult SICH patients treated in our ED from January 1, 2012 to December 31, 2016 were selected as the eligible cases from our hospital's stroke database. Patients' information was comprehensively reviewed from the database and medical and nursing charts. ED-DNR orders were defined as DNR orders written during ED stay. Multiple logistic regression analysis was used to identify significant determinants of ED-DNR orders. Thirty- and 90-day neurological outcomes were analyzed to test the prognosis impact of ED-DNR orders.

RESULTS

Among 835 enrolled patients, 112 (12.1%) had ED-DNR orders. Significant determinant factors of ED-DNR orders were age, ambulatory status before the event, brain computed tomography findings of midline shift, intraventricular extension, larger hematoma size, and ED arrival GCS ≤8. Patients with and without ED-DNR orders had a similar 30-day death rate if they had the same initial ICH score point. During 30 to 90days, patients with ED-DNR orders had a significantly increased mortality rate. However, the rate of improvement in neurological status between the two groups was not significantly different.

CONCLUSIONS

Older and sicker SICH patients had higher rate of ED-DNR orders. The mortality rates between patients with and without ED-DNR orders for each ICH score point were not significantly different. During the 30-to-90-day follow-up, the rates of neurological improvement in both groups were similar.

A qualitative study to identify barriers to local implementation of prehospital termination of resuscitation protocols

BACKGROUND

Despite the existence of national American Heart Association guidelines and 2 termination-of-resuscitation (TOR) rules for ceasing efforts in refractory out-of-hospital cardiac arrest, many emergency medical services agencies in the United States have adopted their own local protocols. Public policies and local perceptions may serve as barriers or facilitators to implementing national TOR guidelines at the local level.

METHODS AND RESULTS

Three focus groups, lasting 90 to 120 minutes, were conducted at the National Association of Emergency Medical Services Physicians meeting in January 2008. Snowball sampling was used to recruit participants. Two reviewers analyzed the data in an iterative process to identify recurrent and unifying themes. We identified 3 distinct groups whose current policies or perceptions may impede efforts to adopt national TOR guidelines: payers who incentivize transport; legislators who create state mandates for transport and allow only narrow use of do-not-resuscitate orders; and communities where cultural norms are perceived to impede termination of resuscitation. Our participants suggested that national organizations, such as the American Heart Association and American College of Emergency Physicians, may serve as potential facilitators in addressing these barriers by taking the lead in asking payers to change reimbursement structures; encouraging legislators to revise laws to reflect the best available medical evidence; and educating the public that rapid transport to the hospital cannot substitute for optimal provision of prehospital care.

CONCLUSIONS

We have identified 3 influential groups who will need to work with national organizations to overcome current policies or prevailing perceptions that may impede implementing national TOR guidelines.

Identification of inpatient DNR status: a safety hazard begging for standardization

BACKGROUND

Ascertaining and documenting patients' preferences regarding end-of-life care is required by accrediting organizations at hospital admission. However, hospitals vary widely in their methods of making these preferences (including do-not-resuscitate [DNR] status) available to frontline providers, increasing the potential for errors.

METHODS

We surveyed 127 nursing executive members of the University HealthSystem Consortium (an alliance of academic medical centers), asking them to describe the current practices of their hospitals in identifying DNR orders. For those at institutions using color-coded wristbands, we also asked about other patient data depicted by wristbands and the choice of colors for DNR and these other indications. We used a commercial online survey tool with E-mail distribution.

RESULTS

Sixty-nine nurse executives completed the survey (54%). Fifty-six percent of hospitals use paper documentation as their only mode to identify DNR orders, 16% use electronic health records, and 25% augment either paper or electronic documentation with a color-coded patient wristband. Of those using color-coded wristbands (n = 17), 8 color schemes were reported. More than 70% of respondents recalled situations when confusion around a DNR order led to problems in patient care.

CONCLUSIONS

Mechanisms to identify DNR orders vary significantly. For hospitals that use color-coded wristbands, the variety of color choices poses a risk for confusion and error. Building on existing and isolated state initiatives, a national mandate to standardize DNR identification and the color of patient wristbands would reduce the potential for errors and promote adherence to patients' wishes.

Implementation of a novel prehospital advance directive protocol in southeastern Ontario

INTRODUCTION

Do not resuscitate (DNR) orders are commonly accepted in most health care settings, but are less widely recognized in the prehospital setting. We describe the implementation of and satisfaction with a prehospital DNR protocol that allows paramedics to honour verbal and non-standard written DNR requests.

METHODS

This prospective observational study reviewed all cardiac arrests in southeastern Ontario between March 1, 2003 and September 31, 2005. Following a verbal or non-standard written DNR request, paramedics completed a questionnaire and a follow-up structured telephone interview was conducted with surrogate decision makers (SDMs).

RESULTS

There were 1890 cardiac arrests during the study period, of which 86 met our inclusion criteria. Paramedic surveys were available for 82 cases (95%), and surrogate decision makers (SDMs) were successfully contacted in 50 (58%) of them. Two SDMs declined to be interviewed. The mean patient age was 72.7 (standard deviation 13.8) years and 65% were male. Sixty-three (73%) of DNR requests were verbal, and 23 (27%) were written. The mean paramedic comfort was rated 4.9 on a 5-point Likert scale (with 5 being "very comfortable") (95% confidence interval [CI] 4.9-5.0). The mean SDM comfort was rated by paramedics as 4.9 (95% CI 4.8-4.9). SDMs reported comfort in withholding CPR in 47 of 48 cases (98%), and with paramedic care in all cases. One SDM stated that although it was consistent with the patient's wishes, she was uncomfortable having to make the DNR request.

CONCLUSIONS

Satisfaction with this novel prehospital DNR protocol was uniformly high among paramedic and SDM respondents. It appears that such a protocol is feasible and acceptable for the prehospital setting. Our conclusions are limited by a small sample size, the lack of a comparison group, and limited follow-up.

Moral moments at the end of life

Decision making near the end of life can be complex and laden with emotion for families and health care providers. Families and patients can prepare themselves for these difficult moments by thinking ahead about the patient's wishes and preparing clear documents that express those wishes. Health care providers can prepare themselves by being familiar with those documents, considering the goals of treatment, remembering the principles on which health care ethics are founded and knowing decision-making models that will help them to think through treatment plans and the best options for patient taking into consideration the goals of treatment.

The Physician Orders for Life-Sustaining Treatment Program: Oregon Emergency Medical Technicians' Practical Experiences and Attitudes

OBJECTIVES

To evaluate emergency medical technicians' (EMTs) experiences with the Physician Orders for Life-Sustaining Treatment (POLST) program and learn about attitudes regarding its effectiveness.

DESIGN

Anonymous survey mailed to a stratified random sample.

SETTING

Tri-County Portland, Oregon, area.

PARTICIPANTS

A total of 572 Oregon EMT respondents (out of 1,048 surveys) were included in the analysis.

MEASUREMENTS

Survey questions about experiences with the POLST form and opinions about POLST.

RESULTS

Respondents were mostly male (76%) and paramedics (66%). Most respondents (73%) had treated a patient with a POLST, and 74% reported receiving education about POLST. EMTs reported that POLST, when present, changed treatment in 45% of cases. Seventy-five percent of the respondents agreed that the POLST form provides clear instructions about patient preferences, and 93% agreed that the POLST form is useful in determining which treatments to provide when the patient is in cardiopulmonary arrest. Fewer (63%) agreed that the form is useful in determining treatments when the patient has a pulse and is breathing.

CONCLUSION

Most respondents have experience with the POLST program. EMTs find the POLST form useful and often use it to change treatment decisions for patients.

Prehospital DNR orders: what do physicians in Washington know?

OBJECTIVES

To assess whether physicians know of Washington State's prehospital do-not-resuscitate (DNR) policy, 6 years after its implementation.

DESIGN

Cross-sectional survey.

SETTING

Washington State, April 2001.

PARTICIPANTS

Four hundred seventy-one practicing physicians.

MEASUREMENTS

Multivariate logistic regression was used to determine relationships between physician and practice characteristics with knowledge of policies governing advance care planning.

RESULTS

Among respondents, 60% did not know that Washington State requires an emergency medical service (EMS)-specific DNR order authored by a physician. Seventy-nine percent did not know that patient-authored advance directives apply only in hospitals and medical offices.

CONCLUSION

The findings in this study suggest that most physicians in Washington State lack knowledge about the documentation needed for EMS personnel to forgo pre-hospital attempts at cardiopulmonary resuscitation. Further study is needed to determine whether physician education or legislative change is necessary.

Communicating advance directives from long-term care facilities to emergency departments

Many residents of long-term care (LTC) facilities are transferred to Emergency Departments without advance directives (AD). The goal of this study was to describe an ideal model for the transfer of AD from LTC facilities to Emergency Departments. Health care providers were asked to describe their ideal model for the completion and transfer of the ADs of LTC residents. A grounded theory methodology was used to identify significant themes. The model we present as a result of this analysis acknowledges the importance of simplifying and standardizing ADs, but focuses more attention on the process of completing and transferring the AD. A key feature of this model is an emphasis on the education of LTC residents and their relatives about ADs and advance-care planning. This education should involve a variety of resources used in creative ways; it should begin as soon as LTC placement is being considered, and the emphasis should be on providing information and discussing options rather than pressuring residents to make a decision.