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second level
third level
fourth level
fifth level
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/div>
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le
E
C
Module
11: Withholding, Withdrawing Therapy
© EPEC Project, 2003
Permission to reproduce for educational purposes granted
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![](3D"master07_background.gif")
![](3D"master07_image001.gif")
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Withholding, Withdrawing Therapy
Module=
11
![](3D"master06_background.gif")
![](3D"master06_image003.gif")
Objectives
•K=
now
the principles for withholding or withdrawing therapy
=
;
•A=
pply
these principles to the withholding or withdrawal of
artificial feeding, hydration
ventilation
cardiopulmonary resuscitation
Role of the physician . . .
•T=
he
physician helps the patient and family
elucidate their own values
decide about life-sustaining treatments
dispel misconceptions
•U=
nderstand
goals of care
•F=
acilitate
decisions, reassess regularly
. . . =
Role
of the physician
•D=
iscuss
alternatives
including palliative and hospice care
•D=
ocument
preferences, medical orders
•I=
nvolve,
inform other team members
•A=
ssure
comfort, nonabandonment
Common concerns . . .
<=
span
style=3D'font-weight:normal'>•Legally required to
“do everything?”
•Is withdrawal, withhol=
ding
euthanasia?
•Are you killing the patient when you remove
a ventilator or treat pain?. . .
Common concerns
•Can
the treatment of symptoms constitute euthanasia?
•Is the use of substant=
ial
doses of opioids euthanasia?
Life-sustaining treatments
<=
span
style=3D'font-weight:normal'>•Resuscitation
<=
span
style=3D'font-weight:normal'>•Elective intubation=
3;
<=
span
style=3D'font-weight:normal'>•Surgery
<=
span
style=3D'font-weight:normal'>•Dialysis
<=
/div>
•Blood <=
/span>transfusions,
blood products
<=
span
style=3D'font-weight:normal;visibility:hidden'>•=
<=
span
style=3D'font-weight:normal'>•Diagnostic tests
<=
/span>
•Artifici=
al
nutrition, hydration
<=
span
style=3D'font-weight:normal'>•Antibiotics
8-step protocol to discuss treatment
preferences . . .
l1. Be familiar with policies, statutes
l2. Appropriate setting for t=
he discussion
l3. Ask the patient, family w=
hat
they understand
l4. Discuss general goals of care
. .
. 8-step protocol to discu=
ss
treatment preferences
l5. Establish context for the discussion
l6. Discuss specific treatmen=
t preferences
l7. Respond to emotions
l8. Establish and implement the plan
Aspects of informed <=
span
style=3D'position:absolute;top:51.8%;left:1.09%;width:97.36%;height:49.39%=
'>consent
<=
span
style=3D'font-weight:normal'>•Problem treatment would
address
•What is involved in the
treatment / procedure
•What is likely to happen if the patient =
decides
not to have the treatment
Example 1: Artifical =
feeding,
hydration
<=
span
style=3D'font-weight:normal'>•Food, water are symbol=
s of
caring
Review goals of care
Address misperceptions
Help family with need to give
care
•I=
dentify
feelings, emotional needs
•I=
dentify
other ways to demonstrate caring
teach the skills they need
Normal dying
•L=
oss
of appetite
•D=
ecreased
oral fluid intake
•A=
rtificial
food / fluids may make situation worse
breathlessness
edema
ascites
nausea / vomiting
Example 2: Ventilator withdrawal
<=
span
style=3D'font-weight:normal'>•Assess appropriateness=
of
request
•Role in achieving over=
all
goals of careImmediate extubation
•Remove
the endotracheal tube after appropriate suctioning
•Give humidified air or
oxygen to prevent the airway from drying
• Ethically sound practi=
ce
Terminal weaning
•Rate,
PEEP, oxygen levels are decreased first
• Over 30–60 minut=
es
or longer
•A Briggs T piece may be
used in place of the ventilator
<=
span
style=3D'font-weight:normal'>•Patients may then be
extubated
Prepare the family . . .
. . .
Prepare the family
Ensure patient comfort
<=
span
style=3D'font-weight:normal'>•Anticipate and prevent
discomfort
•Have anxiolytics, opio=
ids immediately
available
<=
span
style=3D'font-weight:normal'>•Be present to assess,
reevaluate
Prevent symptoms
•B=
reathlessness
opioids
•A=
nxiety
benzodiazepines
Preparing for ventilator withdrawal
•Determine
degree of desired consciousness
•Bolus 2-20 mg morphine =
IV,
then continuous infusion
•Bolus 1-2 mg midazolam IV, then <=
span
style=3D'position:absolute;top:62.09%;left:4.95%;width:83.96%;height:9.74%=
'>continuous
infusion
•Titrate
to degree of consciousness, comfort
Prior to withdrawal
•P=
rior
to procedure
discussion and agreement to discontinue
=
with patient (if conscious)
with family, nurses, respiratory therapists
<=
/span>
document on the patient’s chart
Withdrawal protocol–
part 1
part 1
•P=
rocedure
shut off alarms
remove restraints
NG tube is removed
family is invited into the room
pressors are turned off
parents may hold child
Withdrawal protocol–
part 2
•Es=
tablish
adequate symptom control prior to extubation
•H=
ave
medications IN HAND
midazolam, lorazepam, or diazepam
•S=
et
FiO2 to 21%
•A=
djust
medications
•R=
emove
the ET tube
Withdrawal protocol–
part 3 . . .
part 3 . . .
. . .
Withdrawal protocol–
part 3
part 3
•A=
fter
the patient dies
talk with family and staff
provide acute grief support
•O=
ffer
bereavement support to family members
follow up to ensure they are okay
=
Example
3: Cardiopulmonary resusc=
itation
Write appropriate medical orders
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End of Module 11:
Withholding, Withdrawing Treatment
Review Fast Facts
Complete Module 11 Post Assessment
‹header›
‹date/time›=
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Second level
Third level
Fourth level
Fifth level
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‹#›
The withholding and withdrawing of
life-sustaining therapies is ethical and medically appropriate in some
circumstances. Physicians need to develop facility with general aspects of=
the
subject, as well as specific skills and approaches. In this module, general
aspects are discussed first. Then, 3 areas where this general knowledge fr=
equently
needs to be applied are covered: cessation of artificial nutrition/hydrati=
on, ventilator
withdrawal,
and resuscitation.
Facilitating decision making and
implementing decisions about life-sustaining treatments are essential skil=
ls
for physicians. Impediments to good care include misconceptions about legal
and ethical issues, as well as unfamiliarity with the practical aspects of
implementation.
This module discusses approaches to determine and
implement treatment preferences to withhold or withdraw therapy. First,
general principles and approaches are covered as they relate to this subje=
ct.
Then, 3 specific therapies that many physicians discuss with patients are
covered in more detail: artificial nutrition or hydration, ventilatory wit=
hdrawal,
and CPR.
The physician plays an essential =
role in
defining and implementing the medical care plan, and providing continuity =
of
care as the goals evolve and change over time. The physician will often ta=
ke
the lead in initiating discussions about life-sustaining treatment, educat=
ing
patients and families, helping them deliberate, and making recommendations
about the treatment plan. As part of this role, the physician is responsib=
le
for ensuring that the patient’s wishes, and/or the parents’ wi=
shes
if the patient is a child, are documented and supported by the appropriate
medical orders. Advance directives may be in place and helpful, but may not
necessarily make clear how to translate general goals or treatment prefere=
nces
into treatment of the present medical conditions. Consequently, it is crit=
ical
that physicians have the knowledge and skills necessary for discussions,
negotiations, and implementation of decisions related to life-sustaining
treatments.
All states in the US have statutes
covering issues related to withholding or withdrawing life-sustaining
treatments. Institutional policies of many hospitals or other health care
institutions tend to include considerations, perhaps drafted by ethics com=
mittees,
to protect patient’s rights and interests and considerations, perhap=
s crafted
by risk management officers, to protect the institution from risk. Often, =
institutional
policies are written in response to the general legal imperative to, when =
in doubt,
provide treatment to prolong life. If the appropriate goals of care are ot=
her
than “life at all costs,” then the physician needs to write or=
ders
that are specific enough to accomplish the intended goals.
Emergency
medical technicians (EMTs) are regulated by statute, and sometimes by city
ordinance. Although requirements vary, in general EMTs are required to pro=
vide
all resuscitative and life-prolonging treatments unless a physician’s
order is in place to the contrary.
The physician is the only member of=
the
health care team who can ensure appropriate care, if the goals of care are
other than the default mode. It is the physician’s responsibility to
ensure that the patient’s wishes (or parents’ if the patient i=
s a
child) are followed across care settings. In the hospital, one major study
demonstrated that the majority of patients in intensive care unit settings=
die
without attention to issues of life-sustaining treatment. Many of these
patients have undergone some form of invasive medical treatment against th=
eir
previously stated wishes.
All too often, patients are transferred to t=
he
acute-care setting where life-sustaining measures are administered because=
the
appropriate treatment plan and physician’s orders have not been
completed and placed in the patient’s chart. One study demonstrated =
that
fewer than 25% of advance directive orders were carried from the nursing h=
ome
to the acute care hospital. The fact that physician’s orders may not=
transfer
across settings (eg,
nursing home, ambulance, acute care hospital) also exacerbates the
problem.
There are several common concerns=
that
impact decisions about life-sustaining treatments
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var g_animItemsToHide, g_animInteractiveItems, g_animSlideTime;
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These functions control slide navigation
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document.onkeydown =3D _KDH;
document.ondragstart=3DCancel
document.onselectstart=3DCancel
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function Redirect( frmId )
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function SetHasNts( fVal )
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function ToggleOtlText()
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if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) )
rObj.Play()
else if( rObj.playState =3D=3D 2 )
rObj.Pause()
else
return;
}
else if( PPTSld.g_animUseRuntime )
{
narObj =3D PPTSld.document.all("narrationID")
if( narObj )
narObj.togglePause()
}
}
function GetCurSldNum()
{ =20
obj=3DGetHrefObj(gCurSld)
if( obj.mOrigVis =3D=3D 1 )
return obj.mSldIdx
else =20
return gCurSld
}
function GetNumSlds()
{ =20
if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 )
return GetSldList().mNumVisSlds;
else
return GetSldList().mList.length
}
function GetSldNum( href )
{
for(ii=3D0; ii 1 )
PopSldList();
else if( !IsFramesMode() ) {
if( gLoopCont )
GoToFirst()
else
EndShow()
}
}
function GoToPrevSld()
{
ii=3DgCurSld-1
if( ii > 0 ) {
obj=3DGetHrefObj(ii)
while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) )
obj=3DGetHrefObj(--ii)
if( ii =3D=3D 0 ) ii=3D1
GoToSldNum(ii)
}
}
function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) }
function GoToLast()
{
ii=3DGetSldList().mList.length
if( ii !=3D gCurSld )
GoToSld( GetHrefObj(ii).mSldHref )
}
function GoToSldNum( num )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
obj =3D GetHrefObj( num )
obj.mVis=3D1
gPrevSld=3DgCurSld
gCurSld =3D num;
PPTSld.location.replace(MHTMLPrefix+obj.mSldHref)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function GoToSld( href )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
GetHrefObj( GetSldNum(href) ).mVis=3D1
PPTSld.location.replace(MHTMLPrefix+href)
}
function SldUpdated( id )
{
if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return
gPrevSld=3DgCurSld
gCurSld=3DGetSldNum(id)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) }
function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO=
bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) }
function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) }
function CloseWindow() {
if( HideMenu() ) return;
=09
var event =3D PPTSld.event;
if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D=
=3D32 || event.type=3D=3D"click" ) )
window.close( self );
CatchNumKeys( self, event );
}
function Unload() { gIsEndShow=3D0; }
function SetupEndShow() {
gIsEndShow=3D1;
PPTSld.document.body.scroll=3D"no";
PPTSld.document.onkeypress=3DCloseWindow;
PPTSld.document.onclick=3DCloseWindow;
PPTSld.document.oncontextmenu=3D_CM;
}
function EndShow()
{
if( IsFramesMode() ) return
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
doc=3DPPTSld.document
var dir =3D doc.body.dir
if( dir !=3D "rtl" ) dir =3D "ltr";
doc.open()
doc.writeln(' 0) {
PushSldList(sldList,fEnd);
gCurSld =3D 1;
}
else
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
}
function PushSldList(arr,fEnd) {
var ii =3D gSldStack.length;
gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd);
GoToSld( gSldStack[ii].mList[0].mSldHref );
}
function PopSldList() {
if (gSldStack[gSldStack.length-1].fEndShow)
EndShow()
else {
gCurSld =3D gSldStack[gSldStack.length-1].mCurSld;
gSldStack[gSldStack.length-1] =3D null;
gSldStack.length--;
var sldList =3D gSldStack[gSldStack.length-1];
GoToSld( sldList.mList[gCurSld - 1].mSldHref );
}
}
var custShowList=3Dnew Array();
/*********************************************
Navigation button implementation
There are 2 types of buttons: ImgBtn, TxtBtn
implemented as function objects. They share
a similiar interface so the event handlers
can call SetActive, for example, on a button=20
object without needing to know exactly=20
what type of button it is.
**********************************************/
//----------------------------------
function ImgBtn( oId,bId,w,action )
//----------------------------------
{
var t=3Dthis
t.Perform =3D _IBP
t.SetActive =3D _IBSetA
t.SetInactive=3D _IBSetI
t.SetPressed =3D _IBSetP
t.SetDisabled=3D _IBSetD
t.Enabled =3D _IBSetE
t.ChangeIcon =3D null
t.UserAction =3D action
t.ChgState =3D _IBUI
t.mObjId =3D oId
t.mBorderId=3D bId
t.mWidth =3D w
t.mIsOn =3D t.mCurState =3D 0
}
function _IBSetA()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _IBSetI()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0=20
}
}
function _IBSetP()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 )
obj.style.posLeft+=3D1; obj.style.posTop+=3D1
}
}
function _IBSetD()
{ =20
obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 )
obj.style.posTop=3D0=20
}
function _IBSetE( state )
{
var t=3Dthis
GetObj( t.mBorderId ).style.visibility=3D"visible"
if( state !=3D t.mIsOn ) {
t.mIsOn=3Dstate
if( state )
t.SetInactive()
else
t.SetDisabled()
}
}
function _IBP()
{
var t=3Dthis
if( t.mIsOn ) {
if( t.UserAction !=3D null )
t.UserAction()
if( t.ChangeIcon ) {
obj=3DGetObj(t.mObjId)
if( t.ChangeIcon() )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth
else
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth
}
t.SetActive()
} =20
}
function _IBUI( clr1,clr2,nextState )
{
var t=3Dthis
SetBorder( GetObj( t.mBorderId ),clr1,clr2 )
obj=3DGetObj( t.mObjId )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj=
.style.posTop
t.mCurState=3DnextState
return obj
}
//-----------------------------------------
function TxtBtn( oId,oeId,action,chkState )
//-----------------------------------------
{
var t=3Dthis
t.Perform =3D _TBP
t.SetActive =3D _TBSetA
t.SetInactive=3D _TBSetI
t.SetPressed =3D _TBSetP
t.SetDisabled=3D _TBSetD
t.SetEnabled =3D _TBSetE
t.GetState =3D chkState
t.UserAction =3D action
t.ChgState =3D _TBUI
t.mObjId =3D oId
t.m_elementsId=3D oeId
t.mIsOn =3D 1
}
function _TBSetA()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gHiliteClr,gShadowClr,0,0 )
}
function _TBSetI()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
}
function _TBSetP()
{
if( this.mIsOn )
this.ChgState( gShadowClr,gHiliteClr,1,1 )
}
function _TBSetD()
{ =20
this.ChgState( gFaceClr,gFaceClr,0,0 )
this.mIsOn =3D 0
}
function _TBSetE()
{
var t=3Dthis
if( !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
else
t.ChgState( gShadowClr,gHiliteClr,1,1 )
t.mIsOn =3D 1
}
function _TBP()
{
var t=3Dthis
if( t.mIsOn ) {=20
if( t.UserAction !=3D null )
t.UserAction()
if( !t.GetState )
return
if( t.GetState() )
t.SetPressed()
else
t.SetActive()
} =20
}
function _TBUI( clr1,clr2,lOffset,tOffset )
{
SetBorder( GetObj( this.mObjId ),clr1,clr2 )
Offset( GetObj( this.m_elementsId ),lOffset,tOffset )
}
function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle=
ft }
function SetBorder( obj, upperLeft, lowerRight )
{
s=3Dobj.style;
s.borderStyle =3D "solid"
s.borderWidth =3D 1=20
s.borderLeftColor =3D s.borderTopColor =3D upperLeft
s.borderBottomColor=3D s.borderRightColor =3D lowerRight
}
function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] }
function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() }
function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() }
function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() }
function BtnOnUp()
{
b=3DGetBtnObj()
if( b !=3D null )
b.Perform()
else
Upd()
}
function GetNtsState(){ return parent.gNtsOpen }
function GetOtlState(){ return parent.gOtlOpen }
function GetOtlTxtState(){ return parent.gOtlTxtExp }
function NtsBtnSetFlag( fVal )
{
s=3Ddocument.all.item( this.m_flagId ).style
s.display=3D"none"
if( fVal )
s.display=3D""
else
s.display=3D"none"
}
function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etActive() }
function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etInactive() }
function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etPressed() }
function _BSetA_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]=20
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _BSetI_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0
}
}
var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"=
THREEDFACE"
var gBtnArr =3D new Array()
gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan=
e,GetOtlState )
gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt=
lPane,GetOtlState )
gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN=
tsPane )
gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg;
gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg;
gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.=
ToggleNtsPane,GetNtsState )
gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To=
ggleNtsPane,GetNtsState )
gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n=
b_prevBorder",30,parent.GoToPrevSld )
gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n=
b_nextBorder",30,parent.GoToNextSld )
gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent=
.FullScreen )
gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa=
rent.FullScreen,null )
gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent=
.FullScreen,null )
gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice=
","nb_voiceBorder",18,parent.ToggleVNarration )
gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT=
xt","nb_otlTxtBorder",23,parent.ToggleOtlText )
gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts"
gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag
gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState
/*********************************************
Context menu implementation
_CM() is the function that's hooked up to
the oncontextmenu event. Once we're asked to
show the menu, we first build it by creating
DIVs on-the-fly. Then we position it=20
within the screen area so it doesn't get
clipped.
Creating the DIVs using createElement() means
we don't have to write out any extra HTML
into the slide HTML files.
**********************************************/
var sNext=3D"Next",sPrev=3D"Previous",sEnd=3D"End Show",sFont=3D"Arial",sAr=
row=3D"Arrow",sFreeform=3D"Freeform",sRect=3D"Rectangle",sOval=3D"Oval"
function ShowMenu()
{
BuildMenu();
var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y=
=3DPPTSld.event.clientY+doc.scrollTop
m =3D PPTSld.document.all.item("ctxtmenu")
m.style.pixelLeft=3Dx
if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) )
m.style.pixelLeft=3Dx-m.scrollWidth
m.style.pixelTop=3Dy
if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) )
m.style.pixelTop=3Dy-m.scrollHeight
m.style.display=3D""
}
function _CM()
{
if( !parent.IsFullScrMode() ) return;
if(!PPTSld.event.ctrlKey) {
ShowMenu()
return false
} else
HideMenu()
}
function BuildMenu()
{
if( PPTSld.document.all.item("ctxtmenu") ) return
var mObj=3DCreateItem( PPTSld.document.body )
mObj.id=3D"ctxtmenu"
mObj.style.visibility=3D"hidden"
var s=3DmObj.style
s.position=3D"absolute"
s.cursor=3D"default"
s.width=3D"120px"
SetCMBorder(mObj,"menu","black")
var iObj=3DCreateItem( mObj )
SetCMBorder( iObj, "threedhighlight","threedshadow" )
iObj.style.padding=3D2
CreateMenuItem( iObj,sNext,M_GoNextSld,M_True )
CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld )
=09
CreateSeparator( iObj )
CreateMenuItem( iObj,sEnd,M_End,M_True )
mObj.style.visibility=3D"visible"
}
function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa=
lue=3Dfalse }
function Highlight() { ChangeClr("activecaption","threedhighlight") }
function Deselect() { ChangeClr("threedface","menutext") }
function Perform()
{
e=3DPPTSld.event.srcElement
if( e.type=3D=3D"menuitem" && e.IsActive() )
e.Action()
else
PPTSld.event.cancelBubble=3Dtrue
}
function ChangeClr( bg,clr )
{
e=3DPPTSld.event.srcElement
if( e.type=3D=3D"menuitem" && e.IsActive() ) {
e.style.backgroundColor=3Dbg
e.style.color=3Dclr
}
}
function M_HasPrevSld() { return( parent.HasPrevSld() ) }
function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() }
function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();=
PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() }
function M_True() { return true }
function M_End() { window.close( self ) }
function CreateMenuItem( node,text,action,eval )
{
var e=3DCreateItem( node )
e.type=3D"menuitem"
e.Action=3Daction
e.IsActive=3Deval
e.innerHTML=3Dtext
if( !e.IsActive() )
e.style.color=3D"threedshadow"
e.onclick=3DPerform
e.onmouseover=3DHighlight
e.onmouseout=3DDeselect
s=3De.style;
s.fontFamily=3DsFont
s.fontSize=3D"9pt"
s.paddingLeft=3D2
}
function CreateSeparator( node )
{
var sObj=3DCreateItem( node )
SetCMBorder(sObj,"menu","menu")
var s=3DsObj.style
s.borderTopColor=3D"threedshadow"
s.borderBottomColor=3D"threedhighlight"
s.height=3D1
s.fontSize=3D"0px"
}
function CreateItem( node )
{
var elem=3DPPTSld.document.createElement("DIV")
node.insertBefore( elem )
return elem
}
function SetCMBorder( o,ltClr,rbClr )
{
var s=3Do.style
s.backgroundColor=3D"menu"
s.borderStyle=3D"solid"
s.borderWidth=3D1
s.borderColor=3DltClr+" "+rbClr+" "+rbClr+" "+ltClr
}
------=_NextPart_01C7D83F.C5A40AF0
Content-Location: file:///C:/09782234/Module11WithholdingWithdrawingTreatment_files/fullscreen.htm
Content-Transfer-Encoding: quoted-printable
Content-Type: text/html; charset="us-ascii"
Module 11
------=_NextPart_01C7D83F.C5A40AF0--
in general and withdrawal of ventilator support in particular:
· Are physicians legally required to provide all
life-sustaining measures possible?
No. In contrast, patients have a right to refuse any medical treatment, ev=
en lifesustaining
treatments. There are few exceptions to this rule. Mechanical ventilation =
and
life-sustaining treatments are not exceptions.
· Is withdraw=
al
or withholding of treatment euthanasia? After decades of discussion in
society, there is strong general consensus that withdrawal or withholding =
of
treatment is a decision/action that allows the disease to progress on its
natural course. It is not a decision/action actively to seek death and end
life. Euthanasia actively seeks to end the patient’s life.
· Are you killing the patient when you remove the ventilator
and treat the pain?
The intent and the sequence of actions are important, as are the means cho=
sen.
If the intent is to secure comfort, not death; if the medications are chos=
en
for (and titrated to) the patient’s symptoms as ventilator weaning
proceeds; if the medications are not administered with the primary intent =
to
cause death, then ventilator withdrawal and pain treatment are not euthana=
sia.
Usually, actions intended to provide comfort and freedom from unwanted
intervention result in a slower progression to death than do actions inten=
ded
to euthanize.
Can the treatment of symptoms
constitute euthanasia? For patients who have been using opioids for pa=
in,
it is in fact very hard to give such high doses of opioids that death is
caused (or even hastened) in the absence of a disease process that is lead=
ing
to imminent death, particularly if accepted dosing guidelines are adhered =
to.
Patients tend to sleep off the effect if they get too much medication.
However, for the rare circumstances when opioids might contribute to death,
provided the intent was genuinely to treat the symptoms, then opioid use is
not euthanasia. Be careful to avoid the rationale that says, “death =
is
the treatment!” Symptom treatment alleviates symptoms; it does not
intentionally cause death.
· Is it illegal to prescribe large doses of opioids to reli=
eve
symptoms of pain,
breathlessness, or other symptoms? Even very large doses of opioids=
are
both permitted and appropriate, if the intent and doses given are titrated=
to
the patient’s needs. There is a wide range of life-sus=
taining
treatments that might be considered by an individual patient and family. T=
hese
include CPR, elective intubation and mechanical ventilation, surgery,
dialysis, blood transfusions or blood products, artificial nutrition and
hydration, diagnostic tests, antibiotics, other medications and treatments,
and future hospital or ICU admissions.
After determining the general g=
oals
of care, discuss each specific treatment with your patients and families, =
as
appropriate. At a minimum, try to discuss an invasive and a noninvasive
intervention to get a general idea of a patient’s priorities for
treatment.
Decisions about surgery and antibiotics are often strongly
predictive of other invasive and noninvasive decisions, respectively.
Reasonable physicians may disagre=
e about
the extent to which specific treatment preferences ought to be discussed, =
if
such treatment will not help achieve the overall goals. As a rule, the
discussion of general goals of care should precede the discussion of speci=
fic
treatment preferences.
The physician usually conducts discussions of
treatment preferences. Other appropriate members of the health care team m=
ay
enhance the discussion and prevent subsequent conflict within the team. Th=
ey
will have additional time to carry on the dialogue with the patient and
family. The team will also be able to provide valuable emotional support to
the patient, family, and each other.
Even though other members of the
health care team participate and/or conduct the discussion, implementation=
of
any decision requires a physician’s order. The attending physician m=
ust
sign the documentation and assume full responsibility for its accuracy.=
3;
Become familiar with pertinent policies and statutes
Physicians must familiarize themselves with the policies of the institution
and pertinent statutes where they practice. Unfortunately, many
physicians presume that, because their hospital has a specific policy (eg,=
all
patients will have CPR unless otherwise ordered) this practice reflects st=
ate
or federal law. Relatively few states have laws that address specific
treatments, such as the law in New York that addresses CPR. Most states
leave
specific treatment decisions to be decided between patient and
physician. Each institution will have its own policies, and may have devel=
oped
standard forms regarding lifesustaining treatment.
Communicate effectively
When starting a discussion of treatment preferences, follow the approaches=
to communication
outlined in Module 2: Communicating Bad News. Establish the appropriate
setting. Ask what the patient, family, or surrogate understands about the =
current
health situation, and would like to know, before imparting new
information.
Determine/reconfirm =
goals
of care
Determine or reconfirm the general goals of care. Examples are, “Can=
we
review our overall goals for your care?” or, “ Let me tell you
what I understand you want as we plan your care.” Once the general g=
oals
of care have been confirmed, specific life-sustaining treatment preferences
can be discussed.
Establish the context of the discussion
Be sure to establish the context in which or for which treatment planning =
is
being discussed. The classic misstatement on the part of well-meaning
physicians is, “Do you want us to do everything?” This highly
euphemistic and misleading question fails to acknowledge context. When are=
we
talking about? Today, when the patient is quite healthy, or at the very en=
d of
his or her life when facing death? “Everything” is much too
broad
and is easily misinterpreted by families, especially when they f=
eel
“everything” has not, in fact, been done.
Discuss specific treatment preferences
Discuss specific treatment preferences. Use language that the patient will
understand. Use a translator, preferably someone trained in these skills, =
if
necessary. Give information in small pieces. Reinforce the context in which
the decisions will apply. Stop frequently to check for reactions, to ask f=
or
questions, and to clarify misunderstandings.
Reasonable physicians may
argue that it is unnecessary and potentially confusing to patients and
families to ask them to decide about specific treatment preferences. Patie=
nts
and families may be ill served if physicians regard the principle of auton=
omy as
meaning that physicians must offer all possible therapies from which patie=
nts
and families choose, as though they were choosing items from a menu in a
restaurant. Nonetheless, it is often
useful to discuss and recommend
withholding or withdrawing specific treatments in light of the general or
overall goals that have previously been established. Informed consent is a fundamental=
ethical
principle that underlies contemporary medical care. Patients, and parents =
if
the patient is a child, deserve a clear, complete understanding of all
therapies that are being proposed for them. Some will want to know all the
details. Others will prefer not to know anything. Be prepared to describe =
in
simple, neutral terms the aspects of each life-sustaining treatment in a
manner that conforms to the principles of informed consent :
· the problem the treatment would address
· what is involved in the treatment or procedure
· what is likely to happen if the patient decides not to have =
the
treatment
· the benefits of the treatment
· the burden created by the treatment
Respond to emotions
During these discussions, respond to patient and family anxiety, and
acknowledge emotional content. Parents, if the patient is a child, are lik=
ely
to be very emotional and need support from the physician and other members=
of
the health care team. Patients, families, and surrogates may be profoundly
disturbed by the subject matter being discussed. If a physician finds that
emotions are too challenging, ask other colleagues and/or members
of the health care team to assist.
Establish a plan
Establish and implement a plan that is well articulated and understood. The
next steps may be as simple as planning to discuss the subject again at the
next visit, or convening a family meeting to further discuss the proposed
treatment plan. They may be as complex as organizing nursing, social work,=
and
chaplaincy intervention, or assuring that a key family member living out of
town is notified.
Document and disseminate the plan
Discuss treatment plans with other health care professionals so that the p=
lans
may be carried out in a straightforward and organized fashion. In health c=
are
institutions, this involves discussing the plan with nursing and house sta=
ff,
at a minimum. Write the appropriate orders, document the discussion in the
medical record, and talk about the plan with other members of the health c=
are
team.
Application of the protocol
Three common examples of the application of the protocol to discuss the
withholding or withdrawing of therapy follow.
Physicians frequently perceive the
discussion about whether or not to use or continue artificial feeding and<=
b>/or
hydration to be difficult. Successful approaches are not customarily
demonstrated during medical training. Food and water are widely held symbo=
ls
of caring, so withholding of artificial nutrition and hydration may be eas=
ily misperceived
as neglect by the patient, family, or other professional and volunteer car=
egivers.
The following
are key points, in addition to the general approaches described
above:
First, establish the overall goal=
s of
care. Talk about the general medical condition. Evaluate the ability of
artificial hydration and nutrition to help achieve those goals, before
discussing specifics. For example, if the patient has advanced cancer,
establish an understanding of the overall situation. What is the expected
course of the cancer? Is anything reversible? Second, how will artificial
hydration and nutrition contribute to the overall goals of care, or improve
the situation? If the patient and family hope to see improved energy, weig=
ht,
and strength, then artificial fluid and nutrition may not help accomplish
those goals. Help the patient and family to understand the goals for which
artificial nutrition
and hydration would be appropriate
During the discussion, listen for
misperceptions expressed by patients and families. They may believe that l=
ack
of appetite and diminished oral intake of fluids is causing the
patient’s level of disability. Most then make the assumption that, if
only the patient got more fluids and nutrition, he or she would be stronge=
r.
Use clear, simple language to help them focus on the true causes of the
situation: eg, “The cancer is taking all of your strength” or,
“The fact that your heart is so weak is what is causing you to lose =
your
appetite and feel so fatigued.”
If the patient is close to dying,
make sure the family knows that a dry mouth may not improve with intraveno=
us
fluids. Relief is much more likely with attention to mouth care and oral
lubricants.
In some patients, delirium may be related to dehydration,=
so
a clinical trial of intravenous fluids may be warranted. However, before
starting, ensure that everyone is aware that there are other causes of
delirium that may not respond to fluids, and there is a risk that fluids w=
ill
only increase other physical symptoms (eg, edema, breathlessness) without
relieving the delirium.
Urine output normally declines in the patient =
who
is dying; it is not just an indicator of hydration. Urine output in the ra=
nge
of 300 to 500 mL/day is adequate. The large volumes (2 to 3 L/day) that
physicians and other health care professionals associate with hospitalized
patients are usually the result of intravenous infusions and do not reflect
normal output with oral hydration. Both high-volume infusions and excessiv=
e urination
may be a source of discomfort to the patient.
As part of the discussion, identify the emotional need that providing
food and water
meets, particularly for families. Don’t just address issues of
artificial hydration and nutrition. Help the family find ways to redirect
their desire to be caring, and teach them the skills they need to be
effective.
Loss of appetite and diminished =
fluid
intake are a part of normal dying. Trying to counteract the natural trends=
may
lead to more discomfort for the family without affecting the outcome.
=
Near
the end of life, patients and families may be concerned that there will be=
suffering
from thirst or hunger if the patient is not taking any fluids or nutrition.
Help the patient and caregiving family to understand that dehydration is a
natural part of the dying process.
It does not affect the dying patien=
t in
the same way as a healthy person who feels thirsty on a hot day or becomes
dizzy on standing.
Let family members know that if the patient is not
hungry, artificial fluids and hydration will not help him or her feel bett=
er.
Badgering the patient to eat or drink more will only increase tensions and=
may
cause the patient to become angry, depressed, or withdrawn, if he or she
cannot comply.
In addition, make sure that family members and caregive=
rs
know that artificial fluids and nutrition may make edema, ascites, pulmona=
ry
and other secretions, and dyspnea worse, particularly if there is signific=
ant
hypoalbuminemia.
Ensure that family and caregivers know that a state of
dehydration in a patient who is bed-bound and imminently dying may have so=
me
benefits. Pulmonary secretions, vomiting, and urinary incontinence may be
less. Dehydration may actually stimulate the production of endorphins and
other anesthetic compounds that help to contribute to a peaceful, comforta=
ble
death for many patients.
For many physicians, there is a
relatively rare need to supervise withdrawal of a ventilator when death is
expected. However, the withdrawal of ventilator support from a patient is =
one
of the most challenging situations for patients, families, and their careg=
ivers,
and members of the health care team.
The purpose of this section is to
describe an approach (based on the literature and expert opinion) that can
guide the physician through such an encounter. While there are no tested
protocols, if you are uncertain, seek the assistance of experienced collea=
gues
and other health care professionals to help in the process.
In discuss=
ing
whether to institute or withdraw artificial ventilation, follow the genera=
l outline
for discussing life-sustaining treatments that began this module. Assess w=
hether
removal from the ventilator is appropriate and desired (elements of that a=
ssessment
are described in the references). First, discuss the overall goals in ligh=
t of
the patient’s medical condition. Then, consider the role that artifi=
cial
ventilation might play in achieving
those goals.
In immediate extubation, the
endotracheal tube is removed after appropriate suctioning. Humidified air =
or
oxygen is given to prevent the airway from drying. This is the preferred
approach to relieve discomfort if the patient is conscious, the volume of
secretions is low, and the airway is unlikely to be compromised after
extubation.
While most authorities regard immediate extubation as
ethically sound practice, some may be concerned that it is a form of direct
killing of the patient. In such an action the intent becomes the primary
concern. Secondary consequences can be dealt with, if they occur.
Techniques for ventilator withdrawal
If ventilator withdrawal seems appropriate to everyone involved, consider
which of these
two methods might be used:
1. Immediate extubation (removal of the endotracheal tube)
2. Terminal weaning
The clinician’s and patient’s comfort, and the family’s
perceptions, should influence the
choice of the method to use.
In what some have called terminal
weaning, the ventilator rate, positive end-expiratory pressure (PEEP), and
oxygen levels are decreased while the endotracheal tube is left in place.
Terminal weaning may be carried out over a period of as little as 30 to 60
minutes or longer. CO2 narcosis may stimulate endorphin release and furthe=
r sedate
the patient. If the patient survives, a Briggs T-piece may be used in plac=
e of
the ventilator, if the endotracheal tube will be left in place. Alternatel=
y,
patients may then be extubated.
When removing a patient from the
ventilator, it is critical that the patient be comfortable throughout the
procedure and afterwards. The most important and prevalent symptoms are
breathlessness and anxiety.
Breathlessness
Opioids (such as morphine) are the most effective medication for relieving=
the
sense of breathlessness. They work through both central and peripheral
mechanisms of action. The principle of intended vs unintended consequences
governs their use in this setting.
Concerns about unintended secondary
effects, such as shortened life, are exaggerated, particularly if establis=
hed
dosing guidelines are followed. Titate the dose with the intent to achieve
comfort. Increased doses beyond the levels needed to achieve comfort or
sedation in order to hasten death would constitute euthanasia. Oxygen is h=
elpful
to correct hypoxemia, but not necessarily breathlessness.
Anxiety
Benzodiazepines such as midazolam, lorazepam, and others are the most
effective anxiolytic drugs in this setting. They are usually used in
combination with opioids for severe breathlessness. Opioids only have
transient and unreliable anxiolytic effects in opioidnaive patients and sh=
ould
not be used for this purpose
If the patient is conscious, det=
ermine
if he or she would like to remain conscious as the ventilator is withdrawn.
This will determine the endpoints for initial medication and guide the use=
of
additional medication during the procedure. If the patient wishes to remain
awake, institute opioids and benzodiazepines at low doses. Make plans to i=
ntervene
if severe breathlessness or discomfort ensues after extubation. Determine,=
with
the patient
and family, how and when you would decide to titrate to an endpoint of
sedation.
In planning for discontinuation, a skilled clinician must assess and
reevaluate the patient’s choice and situation. Anticipate potential
discomfort and institute appropriate medical and nonmedical measures in
advance to prevent these symptoms from occurring.
Have medication
immediately available at the bedside so that it can be rapidly titrated to=
the
level appropriate to ensure the patient’s comfort.
Before
withdrawing the ventilator, ensure that the patient is comfortable. If the
patient is naive to opioids and benzodiazepines, start by giving the patie=
nt a
bolus dose of 2 to 10 mg of morphine IV to prevent breathlessness. For
children, dose the medications with advice from a pharmacist or pediatric
intensivist. Follow this initial dose with a continuous morphine infusion =
at
50% of bolus dose/h to maintain the desired effect. Also, bolus
with a dose of 1 to 2 mg of midazolam IV and begin a midazolam infusi=
on
at 1 mg/h.
Titrate these medications to minimize anxiety and achieve the desired stat=
e of
comfort and sedation. Lorazepam may be used as an alternative. If these
medications have been in use routinely and pharmacologic tolerance has
developed, higher doses will be required.
There is no need to increase=
the
doses once comfort and the desired level of sedation have been achieved.&#=
13;If
distress ensues once the ventilator is withdrawn, aggressive symptom contr=
ol
is needed. Consider using morphine, 5 to 10 mg IV push q 10 min, and/or
midazolam, 2 to 4 mg IV push q 10 min, until distress is relieved. Adjust =
both
infusion rates to maintain relief.
In addition to fulfilling all the
requirements of informed consent in a good decion-making process, there sh=
ould
be discussion and agreement with the patient if he or she is conscious and=
the
family when to proceed with discontinuing life support. In addition, nurse=
s,
respiratory therapists and all professional staff on the unit should under=
stand
this development, and have the opportunity to discuss the plan of care. En=
courage
family to
make arrangements for special music or rituals that may be
important to them. If the patient is a child, ask parents if they would li=
ke
to hold the child as he or she dies. Make arrangements for young siblings =
to
have their own support if they are to be present.
Document issues, clinical findings, and care plan on the patient̵=
7;s
chart.
The physician should personally supervise that all monitors and alarms when
possible in the room are turned off. Ensure that staff is assigned to over=
ride
alarms that cannot be turned off if they are triggered. All restraints sho=
uld
then be removed. Clear a space for family access to the bedside. Before the
family comes into the room, remove NG tube and any other needlessly
disfiguring or unnecessary device that may be crowding the
bedside. At
this point, invite the family into the room to be with the patient. If the=
patient
is an infant or young child, offer to have the parent hold the child. Then
turn off the pressors. Maintain intravenous access for administration of
palliative medications.
Establish adequate symptom contr=
ol prior
to extubation as described above. As the family has been told that tachypn=
ea
or periodic breathing can occur, but will be managed, the physician or
assisting nurse should have a syringe of a sedating medication such as
midazolam, lorazepam, or diazepam in hand, to use in case distressing
tachypnea or other symptoms occur.
Once initial symptom control has be=
en
established, set the FiO2 on the ventilator to 21%, and observe the patient
for signs of respiratory distress. Adjust opioids and benzodiazepines to
relieve distress before proceeding further. If a patient is likely to deve=
lop
CO2 narcosis with a decrease in ventilator settings, there may be less need
for sedating medications.
If the patient appears comfortable, prepare =
to
remove the endotracheal tube. Try a few moments of “no assist”
before the endotracheal tube is removed. When ready to proceed, first defl=
ate
the endotrachial (ET) tube cuff. If possible, someone should be assigned to
silence, turn off the ventilator, and move it out of the way. Once the
=
;cuff
is deflated, remove the ET tube under a clean towel which collects most of=
the
secretions and keep the ET tube covered with the towel. If oropharyngeal
secretions are excessive, suction them away.
The family can now come forward =
to a
loved one whose face is no longer encumbered by medical devices. A nurse
should be stationed at the opposite side of the bed with a washcloth and o=
ral
suction catheter. The family and the nurse should have tissues for extra
secretions, and for tears. The family should be encouraged to hold the
patient’s hand and provide assurances to their loved one. After the
patient dies, follow the approaches discussed in Last Hours of Living for expected
death. There is no need to rush anyone. Encourage the family to spend as m=
uch
time at the bedside as they require. Provide acute grief support.
Once
they are ready to leave, provide the family with the physician’s name
and phone number, if they have any questions. Offer follow-up bereavement
support. Send a bereavement card to family members
Many physicians perceive the dis=
cussion
about whether or not to use CPR to be difficult.
This may be due, in p=
art,
to the fact that successful approaches are not customarily demonstrated du=
ring
medical training. Often, the attending physician conducted such discussions
alone, behind closed doors. Sometimes, these discussions were assigned to a
lone medical student or resident to do after rounds.
It is worth
reflecting on the language that has developed around CPR and DNR status, p=
articularly
in hospitals. Getting the DNR order is an important goal for physicians. &=
#8220;Is
he or she a DNR?” has become shorthand for the more pertinent questi=
on,
“What are the goals of care?” Too frequently, a DNR order is
interpreted to imply a whole host of other decisions that, in fact, may or=
may
not have been made about an individual patient.
The focus of this sect=
ion
and, in fact, of the entire EPEC curriculum is to place specific decisions
about medical treatment into the context of whole-person care and respect =
for
the individual. DNR status should never be addressed in isolation. The phr=
ases,
“She is a DNR” and, “He is a full code” betray the
bizarre way in which decisions about resuscitation are sometimes treated in
contemporary medical care.
One impetus to the current state of affairs=
is
the emotional subtext related to “doing everything” for someone
who is loved. It should be expected that everyone involved—patient,
family, physician, health care team—wants to do everything possible =
to
achieve the health and well-being of the patient. Cardiopulmonary resuscit=
ation
is but one medical treatment that may or may not help to achieve realistic
goals related to the care of the patient.
It is helpful to first ident=
ify
the goals of care. It is the physician’s role to facilitate the iden=
tification
of those goals, and then help to determine the medical care that will best=
achieve
them. Then, in the setting of advanced progressive illness where the progn=
osis
is limited, consider carefully whether CPR will help achieve the goals that
the patient, the family, and the physician have collectively determined. U=
sing
this approach, the discussion of
CPR and DNR status become deemphasize=
d to
the point that they almost disappear as important parts of the
discussion.
Discussing DNR status
Establishing DNR status is but one example of advance care planning. When =
undertaking
to establish DNR status, the physician may want to consider a range of sce=
narios,
not just the one that appears to be the most pressing. This may also give =
the discussion
a greater sense of proportion. Before discussing a DNR order, confirm the =
patient’s
(or parents’ if the patient is a young child) understanding about the
overall medical condition, and the context in which you are discussing the=
use
of CPR. Engaging in a discussion that focuses only on CPR and
DNR stat=
us
may leave the patient and family confused and anxious, imagining the preci=
pice
toward which the patient is speeding.
During the discussion, use langu=
age
that is understandable, such as, “If you should die in spite of our
current therapy, do you want us to use ‘heroic measures’? To do
CPR? To press on your chest and put a tube in your lungs to try to get your
heart and breathing started again?” To a layman, when the heart and/=
or
lungs stop, the patient dies. It may be helpful to use the word
“death” to clarify that CPR is a treatment that tries to
temporarily
stop death from occurring. If the patient and family want =
more
information, move to specific descriptions of what is involved with CPR af=
ter
the more general question is answered.
The convention of initially
discussing CPR as “starting the heart” or “putting on a =
breathing
machine” implies a false sense of reversibility, or suggests those h=
eart
and lung functions are isolated problems. Avoid implying that the impossib=
le
is possible. In discussing DNR status with a patient with a life-threateni=
ng
illness, avoid introducing CPR as “shocking the heart if it stops, u=
sing
a breathing machine if the lungs stop.” This reductionist approach f=
ails
to acknowledge the context in which CPR would be administered—to a
patient who is dying of a disease. In the setting of advanced illness,
circulation and breathing stop because of the relentless progression of the
disease. If there were something to reverse, the medical team would do so =
long
before the patient stopped
breathing.
DNR order
CPR involves the establishment of a patent airway, effective breathing, and
cardiac output through assisted ventilation and external cardiac massage. =
If
this is not appropriate or desired by the patient, the physician should wr=
ite
a DNR order. A DNR order does not address any aspect of care other than
preventing the use of CPR. Some institutions prefer a do not attempt
resuscitation (DNAR) to avoid the implication of success that DNR
connotes.
DNI order
A do not intubate (DNI) order is sometimes used for patients who do not ev=
er
want a ventilator used, even if the machine could save their lives. For
example, patients with chronic or progressive lung diseases may choose an
isolated DNI order. Patients who
choose to have a DNR order have impli=
ed a
DNI order, as CPR requires the establishment
of airway, breathing, and circulation.
Do-not-transfer order
Some long-term care institutions may permit a “do-not-transfer”
order to indicate preferences
not to be transferred to an acute hospital setting, in the event of
clinical decline.
Other orders
Include all positive orders that relate to symptom control and those that
guide intensity of care. Some institutions have special forms to facilitate
communication and document orders. A good example is the POLST (Physician
Orders for Life-Sustaining Treatment), which is being used extensively in
Oregon
Withholding and withdrawing ther=
apy
challenge physicians to be excellent communicators with patients and famil=
ies.
Working to help patients and families achieve their goals and understand t=
he
limits of modern medical help can be rewarding when information and skills=
are
learned.
' + ENDSHOW_MESG + '
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