1. Kritikus Foundation Aug 2016
DOARS
determining and ORDERING APPROPRIATE RESUSCITATION STATUS
Recognizing Patient Goals of Care Matching Interventions to Goals
Kritikus Foundation
Aug 2016
©KDMC STaRRS 2011

2. More suffering and more money for little benefit
What’s the problem?
Patients receive care that will not improve their quality of life
Medical service industry provides costly resources that will have no or little benefit
Patients suffering is prolonged without a significant upside
More suffering and more money for little benefit
©2011 STaRRS Education Presentation

3. ©2011 STaRRS Education Presentation
What’s the problem?
Misunderstanding about patient autonomy
Patients have the responsibility of determing their goals of care
Doctors have the responsibility to determine what therapies are indicated based on:
Patient goals of care
Their medical condition
Abdication of physician responsibility in CPR determination
Physicians tend to allow patients to determine what treatments are appropriate for resuscitation even when they are not medically indicated.
©2011 STaRRS Education Presentation
©KDMC STaRRS 2011

4. So the above does not work!
What works ?
“Do you want everything done ?” – says the Doc, thinking “even if it may not be appropriate for your condition”
“Of course I want everything done” – says the patient, thinking “that is appropriate for my condition”
Disconnect between patient and physician understanding
So the above does not work!
©2011 STaRRS Education Presentation

5. Why do physicians allow patients to determine what medical therapies are indicated in CPR ?
Little or no training in end of life
A belief that all patients are entitled to CPR even when burden greatly out weighs the benefit.
Many Specialist are incentivized to provide life saving therapies; that’s what they do! :
Economic
Heavy work load with focus on cure or palliation without time to provide comfort by the physician - at the bedside through dialogue and touch.

6. DOC - “I will do everything that is appropriate for your condition
What works?
DOC - “I will do everything that is appropriate for your condition
Patient -“Thank you, I want everything that will help me
Puts patient at ease and assured you are acting in their best interest
©2011 STaRRS Education Presentation

7. DO WE ORDER APPORIATE RESUSCITATION STATUS ?
Research and Experience Supports:
Patients “Goals of Care” often do not match physician ordered code status
Confusion abounds regarding the term “DNR“
This often results in confusion, unnecessary suffering and resource utilization
©KDMC STaRRS 2011

8. NATIONAL EFFORTS TO IMPROVE EARLIER RECOGNITION OF GOALS OF CARE
POLST
Association of American Hospice and Palliative care Physicians - AAHPM
“Hospital Do-Not-Resuscitate Orders: Why They Have Failed and How to Fix Them” J Gen Intern Med Jul; 26(7): 791–797.
©2011 STaRRS Education Presentation
©KDMC STaRRS 2011

9. POLST FORM ORDERS If patient has no pulse and is not breathing:
Attempt Resuscitation/CPR
Do Not Attempt Resuscitation/DNR  
Medical Interventions: If patient is found with a pulse and/or is breathing:
Full Treatment  
Trial Period of Full Treatment.
Selective Treatment
Comfort Measures
©KDMC STaRRS 2011

10. RESUSCITATION STATUS POLST ORDERS
You can end up with orders for both Full Resuscitation ( pre arrest) AND DNR (post arrest) on the same patient concurrently :
Creates confusion among providers as what to do.
Leads to frustration of providers and unintended suffering due that often is not consistant with patient goals of care.
©2011 STaRRS Education Presentation
©KDMC STaRRS 2011

11. Less medicine doesn't always mean less life
 The way American medicine usually frames the question of end-of-life care is, do you want doctors to do absolutely everything they can to extend your life, even if those interventions may be horribly painful, or run the risk of terrible complications, up to and including death? Or do you want to give up on the possibility of extra time in order to avoid the pain, suffering, and possible complications of those interventions?
There's a study — and now there have been a bunch of these — but the most scientifically-done one randomized people at Mass General hospital with Stage 4 lung cancer to either get the usual oncology care, or get the usual oncology care plus a palliative-care specialist who discussed this thing that we don't want to discuss. The ones who had that discussion ended up stopping chemotherapy sooner
They ended up choosing hospice earlier. They had less suffering at the end of life. And the fascinating thing is they lived 25 percent longer."
©2011 STaRRS Education Presentation

12. SOLUTION? DOARS education and CPOE order set
Opening the door to Improve the care of our patients
©2011 STaRRS Education Presentation

13. “OARS” PROPOSED RESUSCITATION STATUS CPOE ORDERS
 Full Resuscitation
Limited Resuscitation, continue aggressive care except for limitations ordered below :
No chest compressions
No defibrillation
No intubation (if CPR gets to this point and no intubation is checked then chest compressions are to be stopped)
No Pressors
Not a candidate for ICU or CVICU
No BIPAP
Other_______________________
Comfort pathway
Palliative care consult in addition to above resucitation orders - to further clarify patient’s goals of care and resuscitation status
©2011 STaRRS Education Presentation
©KDMC STaRRS 2011
PHYSICIANS DO NOT EM

14. “OARS” PROPOSED CPOE ORDERS
 Full Resuscitation
Limited Resuscitation - continue aggressive care except for limitations ordered below :
No chest compressions
No defibrillation
No intubation (if CPR gets to this point and no intubation is checked then chest compressions are to be stopped)
No Pressors
Not a candidate for ICU or CVICU
No BIPAP
Other_______________________
Comfort pathway
Palliative care consult to assist with care including further clarification of patient’s goals of care and resuscitation status as ordered above
©KDMC STaRRS 2011
PHYSICIANS DO NOT EM

15. PLAN FOR IMPLEMENTATION OF DOARS
Nursing buy-in
Physician buy-in
Present to MEC
Implement in CPOE
Roll out education to Nursing and Physicians during CPOE implementation
Education will have less impact if rolled out before change i.e. absence of understanding for need of the education.
Minimum utilization of resources - can an only make things better not worse - so no need to delay.
©2011 STaRRS Education Presentation