1. Advanced Care Planning: Code Status Travis Nesbit Ucimc im pgy-1 Minilecture 1/15/2015

2. Objectives  Understand Advanced Care Planning (ACP) Terminology  Utilize a POLST to better understand Code Status  POLST is not required to make code decisions/orders!  Work 3 Example Cases  Gain confidence in leading ACP discussions

3. Background : The problem  “Code Status” discussion happens for every hospitalized patient.  Patients / families often confused by the terminology.  Physicians also often confused by the terminology.

4. Background : Why it’s important  Increased likelihood patients wishes are respected.  Reduced end-of-life hospitalization.  Reduces decision-burden of family members.  Reduces moral distress among health care providers.

5. ACP Terminology: Overview  Part 1: Documents  Question: what are two major ACP documents?  Part 2: Acronyms  Question: what are 4 major ACP acronyms?

6. ACP Documents: Advanced Directive  >= 18 yrs of age  future treatment  Appoints a Health Care Representative  Does not guide emergency medical personnel  Does guide inpatient treatment decisions

7. ACP Documents: POLST  Physician Orders for Life Sustaining Treatment  serious illness at any age  current treatment  Does guide emergency medical personnel  *** Guides inpatient treatment decisions ***  *** Can serve as model for inpatient Code Discussion! ***

8. POLST Sections A-C

9. Accessing ACP Documents  CA Government approved Advanced Directive:  http://ag.ca.gov/consumers/pdf/AHCDS1.pdf http://ag.ca.gov/consumers/pdf/AHCDS1.pdf  Search terms (Google): “California Advanced Directive”  CA Government approved POLST:  http://www.cdph.ca.gov/programs/LnC/Documents/MD S30-ApprovedPOLSTForm.pdf http://www.cdph.ca.gov/programs/LnC/Documents/MD S30-ApprovedPOLSTForm.pdf  Search terms (Google): “California POLST”

10. ACP Acronyms  Do Not Resuscitate (DNR): Do not attempt to perform CPR or any other life-restoring measures.  Do Not Attempt Resuscitation (DNAR): Synonymous with DNR  Allow Natural Death (AND): Definitions appear to vary; CA State approved POLST uses it synonymously with DNR/DNAR.  Do Not Intubate (DNI): Do not intubate under any circumstance, code or not.

11. Hypothetical Case #1  Mr. A is a 30 yr M with asthma presenting with PNA. He is speaking in full sentences, but appears fatigued and his ABG shows a pCO2 of 50.  Dr. K is a 28 yr resident who skillfully elicits a full-code status from Mr. A.

12. Hypothetical Case #1 cont.  Question 1: How would you document this decision in the chart?  Question 2: Although it's unnecessary in this instance, if you were to fill out a POLST which sections would you check off?  Question 3: Would you consider filling out a POLST for this patient?

13. Hypothetical Case #2  Mrs. Jones is also a 96 yr F with h/o 4V CABG, DM2, dementia, multiple pressure ulcers, also presenting from SNF for AMS/fever. She was also admitted by ED to MICU for Septic Shock; she is protecting her airway, but delirious. She comes with an advanced directive identifying her son Gomer as her decision maker.  Dr. K this time is told by Gomer that his mom wouldn’t want to be brought back after she passed, but if she needed a breathing tube and it could be removed that’s okay.

14. Hypothetical Case #2 continued  Question 1 : How would you document this?  Question 2: If we couldn’t find manual BP by cuff, and tele showed wide complex polymorphic tachycardia to 200 bpm would you call a rapid response or a code?  Question 3 : Is this patient okay to intubate in a rapid response? What about in a code?  Question 4: Would you consider filling out a POLST for this patient?

15. Hypothetical Case #3  Mrs. Daisy is a 114 yr F with h/o 4V CABG, DM2 s/p bilateral amputations, prosthetic hip, multiple pressure ulcers, presenting from SNF for AMS/fever. Admitted by ED to MICU for Septic Shock; she is protecting her airway, but delirious. She comes with an advanced directive identifying her son Jeb as her decision maker.  Dr. K contacts Jeb. Jeb says she doesn’t want to be revived, and no invasive breathing machines under any circumstance.

16. Hypothetical Case #3 continued  Question 1 : How would you document this?  Question 2: If this patient had BP 55/33, confused, tachycardic to 180 bmp, and appeared to have respiratory distress would you call a rapid response or a code?  Question 3 : Is this patient okay to intubate in a rapid response? A code?  Question 4: Would you consider filling out a POLST for this patient?

17. Summary  Know POLST and Advanced Directive  Know DNR, DNAR, AND, DNI  A “code” and DNR status is for cardiopulmonary arrest.  DNR and DNI are separate decisions.  DNI applies to all circumstances, not just the code.  A POLST can be a good model for your code discussion.  A “code menu” is not necessary; see the POLST as an ex.

18. References  State of California Department of Justice, Office of the Attorney General. http://ag.ca.gov/consumers/pdf/AHCDS1.pdfhttp://ag.ca.gov/consumers/pdf/AHCDS1.pdf  California Department of Public Health. http://www.cdph.ca.gov/programs/LnC/Documents/MDS30- ApprovedPOLSTForm.pdf http://www.cdph.ca.gov/programs/LnC/Documents/MDS30- ApprovedPOLSTForm.pdf  UpToDate.com. http://www.uptodate.com/contents/advance- care-planning-and-advance-directiveshttp://www.uptodate.com/contents/advance- care-planning-and-advance-directives  Brigham and Womens Faulkner Hospital. http://www.brighamandwomensfaulkner.org/about-us/patient- visitor-information/advance-care-directives/dnr- orders.aspx#.VLhu_XvCf8M http://www.brighamandwomensfaulkner.org/about-us/patient- visitor-information/advance-care-directives/dnr- orders.aspx#.VLhu_XvCf8M