1. Ethics and End of Life Decisions
Jeffrey J. Kaufhold, M.D.
Grandview Hospital

2. Grandview Hospital and Medical Center
“Treat the patient, not just the symptoms”
452 bed facility
Inpatient and outpatient
3 Behavioral Health floors
Over 100 Residents, Interns, and Medical Students
Affiliated with Ohio University College of Osteopathic Medicine
Faith-based organization – part of KMCN

3. Southview Hospital and Family Health Center
Offers surgical, inpatient, and outpatient services
Growing Women's Health Center
Sycamore Women’s Center feeds patients into SVH maternity center.

4. Bioethics Advisory Committee
Provides consultations
Reviews policies
Education
Mentoring

5. Legal, Financial and Quality Issues
Legal – protection
Financial – regulatory agency requirements
Quality – quality indicators
Pain management
Organ donation and reporting
Patient and family satisfaction surveys

6. Key Factors Communication Goals of palliative, comfort care
Evidence based approach
Competency of patient to decide
Pain
Depression
Drug or disease induced delirium

7. Communication Common problems What are the goals?
Communication triangle – patient, doctor, and family
What are the goals?
Understanding the illness
Outcome of treatment

8. Relationship Building
Nursing staff
Medical staff support
Patient/family wishes

9. Goals of Care Palliative and comfort care
DNR does not mean do not treat
What does comfort care involve?
What treatments/medicines are stopped?
What treatments/medicines are started?

10. Principles in Ethical Decision Making
Paternalism
Autonomy
Utilitarianism
Non Malfeasance
Futility
Outcomes Analysis
Levels of Care

11. Definitions Ethics Advance Directives Brain Death Cardiac Arrest
Comfort Care
Decisional Capacity
DNR

12. Definitions DNR Comfort Care DNR Comfort Care Arrest Futile Care
Health Care Power of Attorney
Level of Care Orders
Living Will
Respiratory Arrest
Resuscitation

13. Cultural Issues Cultural perspectives on end of life issues Ethnicity
Religious beliefs
Poverty and illiteracy

14. Resuscitation of Residents with DNR orders in LTCFs
Measured the frequency of EMS calls to ECFs for patients with DNR orders
Calls
DNR (35%)
Resus. Attempted 29 (21%)
Becker Yeargen et al. Prehospiital Emergency Care 2003: 7:

15. The Ohio Law on DNR-CC Creates a portable DNR
Form ID bracelet wallet card
Description of Components of CPR
Stipulates what will NOT be done if pt is DNR
Provides protection from liability

17. Ohio Law on DNR-CC Living will applies to persistent vegetative state.
New version (1999) has provision for establishing DNR arrest or DNR Comfort Care only.

18. Definitions DNR DNR-CC-Arrest
Old terminology, means Do not Resuscitate.
DNR-CC-Arrest
New Terminology, means do not resuscitate: Provide comfort care when the end comes, continue all other treatment until then.

19. Definitions
DNR – CC
Means Comfort Care measures only are to be given. Discuss with pt/family as to whether certain measures could be STOPPED, such as dialysis, Vent support, Lab draws, pressors, antibiotics, etc.

20. Level of Care Orders
Procedure for placing limits on resuscitative efforts
Progress note
Orders
Copy of Ohio DNR – CC form
End of each daily PN should state
“Pt is DNR “

22. Order of Principles Who Decides? Patient’s wishes
Patient’s spokesperson
Caregiver
Physicians on case may invoke futility
Ethics committee or consultant

23. Who to Contact Each hospital has an Ethics Committee
Nursing supervisor, risk manager
Program Chairperson
Write an order
Discuss with attending if appropriate
Attend a committee meeting to learn more!