Tuesday, February 16, 2010

Discussing and documenting resuscitation status

DNR discussions are challenging. Through the years I've noticed several common mistakes which form barriers to meaningful decision making:

Use of medical jargon. Patients and their families watch TV and read newspapers, and think they understand this terminology, but they often don't.

Misunderstanding of clinical issues. A lack of understanding of the patient's disease processes on the part of the person leading the discussion may lead to over or under estimation of the prognosis.

Cursory or hurried discussions. Pressure to adhere to a regulatory or institutional policy may drive such discussions, which are not informative to patients and families.

Discussions postponed until the moment of crisis.

Vague and overly subjective discussions. Early in the conference the patient may say something like “Do whatever you have to if you think it will help” and there ends the discussion. Individual modalities of resuscitation and their anticipated benefits are often not addressed specifically.

Shared assumptions that DNR status means giving up. DNR patients may still warrant aggressive care, including ICU care. At Mayo Clinic, for example, (see below link) DNR status does not preclude the option of intubation and mechanical ventilation for patients who develop respiratory failure.

Issues concerning DNR discussions are reviewed in a recent issue of the Green Journal.

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