2. Source and Credits
• This presentation is based on the July 2003
AHRQ WebM&M Spotlight Case
• See the full article at http://webmm.ahrq.gov
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3. Objectives
At the conclusion of this educational activity,
participants should be able to:
• Appreciate challenges of determining goals of care in
hospitalized patients
• Understand common misconceptions about CPR
• List typical mistakes physicians make when
discussing advanced care planning
• Recognize steps physicians and health care systems
can take to improve advanced care discussions
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4. Case: NFR Status Confusion
A 60-year-old woman with a history of severe
asthma without prior intubations presented to
the ED with shortness of breath. On physical
examination, her BP was 145/85, HR 85,O2 sat
94% with a respiratory rate of 22. Her lung
exam revealed diffuse-end expiratory wheezes
and decreased breath sounds at the bases.
Despite a long-standing relationship with health
care professionals, the patient had not
completed a living will prior to admission.
4
5. Advanced Directives
• 75% of patients who present to the ED do not
have advanced directives
– Even fewer in absence of terminal diagnosis
• When completed, advanced directives are
often unavailable upon hospitalization or are
difficult to interpret
• Hospital-based physicians often discuss NFR
status with patients they have not met
previously
5 Ishihara KK, et al. Acad Emerg Med. 1996;3:50-3.
6. Patients’ Preferences Regarding CPR
• 30% of patients with serious underlying
illness do not want resuscitation
• Physicians cannot accurately predict
patients’ preferences without asking them
6 Hofmann JC, et al. Ann Intern Med. 1997; 127:1-12.
7. Case (cont.): NFR Status Confusion
Upon admission, the H/S spoke with the patient about
NFR status. The patient stated that she “would not want
to be on a tube to breathe.” About CPR, she did not
want “shocks to the heart or pressing on my heart.” She
said if her breathing continued to be this difficult and
she could not live independently, she would rather not
survive. The H/S interpreted these statements as
indicating the patient’s desire for NFR status, and called
the resident to discuss it, but a NFR form was not
completed at that time.
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8. Common Features of
NFR Status Discussions
• Use of vague language
– “Would you want your life prolonged?”
• Use of dire scenarios
– Only 50% of Dr’s present scenarios with
reversible conditions
• Failure to elicit patient concerns and discuss
goals of care
– Rarely clarify “small chance” recovery, poor
quality of life
8 Tulsky JA, et al. Ann Intern Med. 1998;129:441-449.
9. Common Features of
NFR Status Discussions
• Domination of discussion by physician
– Physicians speak nearly three-fourths of the time
• Use of medical jargon
– Without confirming patients understanding
9 Tulsky JA, et al. J Gen Intern Med. 1995;10:436-442.
10. Do Patients Understand CPR?
• Survey results: patients have misconceptions
even after discussions:
– CPR survival estimated to be 70% (in reality is
10%-15%)
– 26% could not identify features of CPR
– 37% thought ventilated patients could talk
– 20% thought ventilators were O2 tanks
– 20% thought people on ventilators were in a coma
10 Fischer GS, et al. J Gen Intern Med. 1998;13:447-454.
11. Case (cont.): NFR Status Confusion
A few hours after admission, the patient had
sudden respiratory failure leading to pulseless
electrical activity (PEA) arrest. As there was no
NFR form in the chart, the nurse called a resus
team and CPR was initiated. The resus team
found the H/S’s initial assessment, which
stated the patient’s preference for no
resuscitation or intubation efforts.
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12. Case (cont.): Code Status Confusion
The registrar had discussed the case briefly
with the H/S (including her interpretation that
the patient wished to be a NFR), but neither
the registrar nor the H/S had discussed NFR
status with the patient. At this time, the
patient’s blood pressure was 90/palpable,
heart rate was 40 and an O2 saturation was
92% with assisted bag-mask ventilation.
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13. The NFR Status Dilemma
• Documentation—No NFR status documented in
chart; therefore, resus initiated
• Autonomy—Patient had expressed wish to be NFR
to H/S on admission
• Beneficence—Team knew prognosis of witnessed
arrest from asthma exacerbation was good
• Informed decision making—Team concerned patient
was not fully informed when she requested to be
NFR on admission
– This is the only ethical justification for overriding a
NFR order
13 Lo B. Promoting the patient’s best interests. In: Resolving ethical
dilemmas: A guide for clinicians (2nd ed.). 2000:30-41.
14. Case (cont.): NFR Status Confusion
The patient did receive cardiopulmonary
resuscitation, including medications and chest
compressions. In an effort to respect her
preference to avoid invasive ventilation, she
was started on noninvasive bi-level positive
airway pressure (BIPAP) ventilation.
Spontaneous respirations returned with
BIPAP, and the patient was stabilized.
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15. Case (cont.): NFR Status Confusion
The next day, the patient was alert and able to
express her thoughts about the events of the
previous night. She had not realized that
intubation could be a temporizing measure—
she thought it meant permanent respiratory
support. She had thought the discussion was
about whether she would want to be kept alive
if she was “a vegetable.”
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16. Case (cont.): NFR Status Confusion
Furthermore, the patient said that she had
not realized that resuscitation attempts could
be successful. After her experience, she
stated that she did want aggressive
interventions for reversible causes.
Her NFR status was changed to full resus.
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17. Tips for Discussing Advanced Directives
• Do more listening and less talking
• Elicit patients’ values and overall goals of
care—match interventions with these goals
• Use simple language
• Make clear the alternative to CPR is death,
and express the likely survival after CPR.
– Distinguish situations where outcomes are better,
such as in the OT or during conscious sedation
for procedures
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18. Tips for Discussing Advanced Directives
• Ask about preferences in scenarios with
uncertain outcomes
– i.e., successful cardiac resuscitation with resultant
severe anoxic brain injury
• Assess the patient’s understanding
– Especially if decision is contrary to what would be
expected in similar patients
• Reassess the patient’s goals of care at every
hospitalization
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19. Recommendations for Hospitals
and Educators
• Standardize the NFR order sheet
– Separate authorization for CPR, intubation, and
vasopressors
– Consider including other life-prolonging
interventions (i.e., tube feeds, antibiotics, dialysis)
that may be instituted in patients who will not
receive CPR
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