Although a number of nursing homes have "no CPR" policies, others mandate that CPR be initiated whenever someone dies who does not have a do-not-resuscitate (DNR) order in place. In these latter facilities, discussions about resuscitation are particularly imperative. In some situations, the person is clearly in cardiac arrest, and initiating CPR is appropriate, absent a DNR order. In other cases, the individual may have been lifeless for a period of several minutes to over an hour, and CPR is an exercise in futility. Nonetheless, facility policy mandates that nurses initiate CPR on all these patients, and continue until "911" arrives and takes over or, in some cases, a physician tells them to stop. Compounding this difficult situation is the dismal success of CPR in the nursing home population.
Learning a patient’s (or family’s) preference for CPR/DNR before an emergency occurs is one way to foster patient autonomy. To help nursing home staff increase the number of discussions with patients and families regarding their preferences for CPR or DNR, a nursing home in New York City tried a quality improvement initiative. The project, funded by the United Hospital Fund and conducted in collaboration with the John A. Hartford Institute for Geriatric Nursing at New York University, was part of a larger initiative designed to improve palliative care in a number of nursing homes in the city.
Process
Members of the interdisciplinary care team participating in the
project were asked to identify an area within palliative care that
was of concern to them. The team members opted to work on improving
advance care planning, specifically, determining their patients’
preferences for DNR or CPR. The team chose three units of the
nursing home and obtained a list of all residents. As the project
began, unit staff were reminded about the importance of learning
their residents’ DNR/CPR preferences. Medical records were reviewed
to determine DNR status. A social worker approached each resident
(when appropriate) or family to discuss their preference for
DNR/CPR.
Early on, the team identified several obstacles to these discussions, which it decided to study. Staff were asked to use a tracking form to record information such as the number of times required to make contact with the resident or family, the number of discussions needed to reach a decision, and length of time it took to reach that decision.
In addition to recording the outcomes on the tracking sheets, the social worker, who generally led most discussions, also noted barriers to decision-making. Institutional barriers included the inaccessibility of DNR forms, and incorrect knowledge about the use and success rate of CPR among nursing home patients. A physician must write the actual DNR order; however, in a number of instances, the physician was unavailable, was reluctant to have any further discussion about DNR, or was unsure of the procedure for obtaining a DNR order (e.g., telephone consent, faxed consent, etc).
Families created some barriers, such as being difficult to contact or providing unclear information regarding the primary contact. Sometimes, family members disagreed about the appropriate decision; in other cases, families who were ambivalent about making the decision responded by avoiding it. Occasionally, language was a barrier.
Results
After four months, conversations had been held with each resident
(or the appropriate family member or primary contact) who had not
previously indicated preferences for DNR/CPR (N=58). Almost 40
percent of the residents finalized their DNR/CPR decisions the day
of the discussion; four out of five residents made their decisions
within one month. In approximately 17 percent of the cases, no
resolution was achieved, but in the remaining cases, a decision was
made. Although the majority opted for DNR, a small proportion asked
that resuscitation be attempted.
Conclusions
In this particular facility, the responsibility for discussing
DNR/CPR has traditionally fallen to the medical staff because they
write the orders. In other facilities, nurses conduct DNR/CPR
discussions, and then the medical director or another physician
simply writes the order. While this is clearly a more efficient
model, it may not appeal to all facilities.
In addition to the very positive result of learning their patients’ preferences for end-of-life treatment, staff appreciated the program’s measurable success. It also clarified that although multiple attempts might be needed to obtain a decision, the majority of decisions were obtained after four attempts at resolution. The results of this study indicate that a methodical and persistent approach to obtaining a final decision from residents and/or families regarding their preference for DNR/CPR can be successful.
Much of this endeavor’s success can be attributed to an interdisciplinary team’s decision to increase the number of discussions about DNR/CPR. Also key were the strong belief by the team leader in the importance of advance care planning discussions, and the commitment of the entire team to the study’s success.
For more information, contact:
Lucia McBee
The Jewish Home and Hospital
120 W. 106th Street
New York, NY 10025
lmcbee2@jhha.org
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