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Not for resusitate
- 1. Not For Resuscitation(NFR) order in Elderly Patient Presented By Rakesh Patel Registered Nurse
- 2. Today’s Talk Will Cover • NFR order in elderly patient • Benefit of having NFR status • When to have NFR order • Advance care planning (ACP) • What it means & how to approach – Tools to help you plan • Care of patient who has signed NFR form. – Common challenges & how to approach
- 3. Abbreviations Used in This Talk • NFR: Not for resuscitation • DNR: Do not Resuscitate. • EOL: End of life • Palliative care • ACP: Advance care planning • AD: Advance directive • DPOAH: Durable power of attorney for health care • POLST/MOLST: Physicians/Medical Orders for Life-Sustaining Treatment
- 4. NFR means Not for resuscitate (NFR) order, a written medical directive that documents a patient's decision regarding his/her desire to avoid cardiopulmonary resuscitation (CPR) in Case of cardiac arrest . • (Butka, B. 2012:1613-1613)
- 5. Cardinal ethical points • Autonomy • Not Malefiency • Justice • Beneficial (Santonocito,. C. 2013: 14–21)
- 6. Benefits of NFR order • Helps elderly and terminally ill patient get the preferred care: – For those who prefer this: can increase chance of dying at home, decrease hospitalizations at end of life • Reduces decision-making stress for surrogate decision- maker. • Can reduce family conflicts over what should be done • NO CPR related complication. • To redirect finite resources to more‘salvageable’ patients (Downar, J., Luk, T., Sibbald, R. W., Santini, T., Mikhael, J., Berman, H., & Hawryluck, L. 2011: 582-587).
- 7. steps for planning NFR 1. Understand health conditions and how they are likely to progress – Hope for best, prepare for likely crises/declines 2. Articulate values and preferences for future care – Includes designating a surrogate decision-maker 3. Document preferences in writing 4. Re-assess preferences and plans periodically
- 8. EXAMPLES WHERE NFR CAN BE USED • Advanced incurable malignancy • advanced multi-organ failure • irreversible, severe, and documented brain damage • advanced cardiac, hepatic, or pulmonary disease • inoperable, life threatening congenital heart disease, fatal chromosomal or neuromuscular disease • Irreversible, severe, mental and physical incapacity. • Advanced incurable, end-stage malignancy • End-stage organ failure • Advanced irreversible brain damage • End-stage renal disease if renal replacement therapy is not feasible • Inoperable congenital anomalies incompatible with life • Fatal chromosomal abnormalities • Brain death.
- 9. COMPONENTS OF A NFR ORDER • Cardiopulmonary resuscitation involving chest compressions and oxygenation • Endotracheal intubation • Mechanical ventilation • Defibrillation • Vaso-active/ionotropic medication
- 10. NFR with Choice • Renal dialysis • Blood transfusion • Parenteral nutrition • Pulmonary hygiene • Normal treatment Including antibiotics
- 11. Preferences & Values for Future Care • What are the Value of Terminal illness person value? – What matters most in life? – What makes life worth living? What sounds worse than death? – What would be an ideal last year? An ideal death? – Feelings about life support? About being hospitalized? About surgeries? About suffering? – At what point, if any, should doctors stop trying to extend life? (Sulmasy, D. P., He, M. K., McAuley, R., & Ury, W. A 2008: 1817-1822)
- 12. Example of patient wishes • – "if I deteriorate I do not want resuscitation or to go to • intensive care, I want to be kept comfortable and dry” • – "I want to die at home and not return to hospital" • – “Please make sure that I die outside, under the stars”
- 13. Document Preferences in Writing • Print or hand-write key points from the process of reflecting & discussing – This information can later help family members & clinicians • Complete a state-approved NFR form – Review with primary care doctor or other clinician if possible • Consider appending key information regarding preferencesConsider POLST/MOLST (Physician/Medical Orders for Life-Sustaining Care) – Bright-colored paper, summarizes key preferences re resuscitation & transfer to hospital – Meant to guide clinicians during a medical emergency – Signed by physician & by patient/DPOAH
- 14. Diffrenent form oF NFR Writing • written bedside orders • wallet identification cards • identification bracelets • predefined paper documents (Loertscher, L., Reed, D. A., Bannon, M. P., & Mueller, P. S. 2010:4-9)
- 15. NSW health NO CPR order form
- 16. Barrier to have NFR order • cultural resistance • Poor communication between patients and doctors • NFR plan are not easily accessible • No systems in place to have NFR • Lack of time in Emergency department to discuss NFR. • Religious belief • Language • Ethics (Fromme, E. K., Zive, D., Schmidt, T. A., Olszewski, E., & Tolle, S. W. 2012: 34-35)
- 17. SUPPORTIVE CARE FOR ALL NFR PATIENTS • Clearance of secretions (oral, throat, etc) • Hydration and nutrition • Pain management, antipyretics, and sedation • Supplemental oxygen • Anti emetics and relieve of constipation • Relief of urinary retention • Relief of dypnea and cough)
- 18. RECOMMENDATIONS • Develop palliative care as an alternative to ICU for DNR. • Training workshops on the ethical issues of EOL • DNR orders to specify interventions intended/prohibited • Respecting the autonomy of physicians who have conscientious objections to DNR • More psycho-social support for DNR families • More empirical research on the DNR process • Regular audits of DNR decisions and outcomes.
- 19. PROTECTION OF THE PATIENT FROM POTENTIAL HARM • Paternalism • Patient consent for CPR • Patient consent for DNR • Family assent to DNR • Age discrimination
- 20. Reassess preferences & plans periodically • Preferences will change over time, as health evolves. • Consider reviewing advance care planning – After new major diagnosis, such as cancer or other life-limiting illness – After major hospitalization – After significant decline in health or abilities (NSW health policy 2011 and Ambulance service of NSW)
- 21. The Role of Caregivers • Caregivers often advocate for the comfort & needs of person with dementia • Caregivers are often surrogate decision- makers • Many families don’t understand how people with advanced dementia decline & die – Better understanding linked to fewer hospitalizations in last 18 months of life • (Weeks, L.E., MacQuarrie, C. & Bryanton, O. 2008:85-93)
- 22. The Role of Palliative Care • Palliative Care: • Assessment and Treatment of Symptoms • Psychosocial, Spiritual, and Bereavement Support • Coordination of Care – Care focused on symptoms and quality of life – Providers have special training in communicating with families and in addressing concerns – Does not equal hospice, or “giving up” (but families sometimes choose hospice if preferences & situation are a good fit) – (Morrison, R.S. & Meier, D.E., M.D. 2004:2582-2590)
- 23. Benefit of Treatment vs. Burden on Patient • Are we keeping the patient alive when there is no benefit to the life of the patient? • Are we giving the patient time to recover to a level of quality of life that the patient will accept, • Or are we merely prolonging or exacerbating the process of death?
- 24. References • • Butka, B. 2012 Do Not Resuscitate. Journal of American medical association 308 16, 1613-1613 • Cohen, R. I., Lisker, G. N., Eichorn, A., Multz, A. S., & Silver, A. 2009 The impact of do-not-resuscitate order on triage decisions to a medical intensive care unit. Journal of critical care, 24 2, 311-315. • Downar, J., Luk, T., Sibbald, R. W., Santini, T., Mikhael, J., Berman, H., & Hawryluck, L. 2011 Why do patients agree to a “Do not resuscitate” or “Full code” order? Perspectives of medical inpatients. Journal of general internal medicine, 26(6), 582-587. • Field, J. M., Hazinski, M. F., Sayre, M. R., Chameides, L., Schexnayder, S. M., Hemphill, R., & Hoek, T. L. V. 2010 Part 1: executive summary 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 122 18 suppl 3, S640-S656. • Fromme, E. K., Zive, D., Schmidt, T. A., Olszewski, E., & Tolle, S. W. 2012 POLST Registry do-not-resuscitate orders and other patient treatment preferences. JAMA, 307 1 , 34-35. • Handy, C. M., Sulmasy, D. P., Merkel, C. K., & Ury, W. A. 2008 The surrogate's experience in authorizing a do not resuscitate order. Palliative and Supportive Care, 6 01, 13-19. • Levin, T. T., Li, Y., Weiner, J. S., Lewis, F., Bartell, A., Piercy, J., & Kissane, D. W. 2008 How do-not-resuscitate orders are utilized in cancer patients: timing relative to death and communication-training implications. Palliative and Supportive Care, 6(04), 341-348. • Loertscher, L., Reed, D. A., Bannon, M. P., & Mueller, P. S. 2010 Cardiopulmonary resuscitation and do-not-resuscitate orders: a guide for clinicians. The American journal of medicine, 123 1, 4-9. • Sulmasy, D. P., He, M. K., McAuley, R., & Ury, W. A 2008 Beliefs and attitudes of nurses and physicians about do not resuscitate orders and who should speak to patients and families about them. Critical care medicine, 36(6), 1817-1822. • Sulmasy, D. P., Sood, J. R., & Ury, W. A. 2008 Physicians’ confidence in discussing do not resuscitate orders with patients and surrogates. Journal of medical ethics, 34(2), 96-101. • Venneman, S. S., Narnor-Harris, P., Perish, M., & Hamilton, M. (2008). “Allow natural death” versus “do not resuscitate”: three words that can change a life.Journal of Medical Ethics, 34(1), 2-6. • Santonocito, C. 2013 Do-not-resuscitate order: a view throughout the world. Journal of • Critical Care 28, 14–21. • Ventafridda,V.2006 Palliative Medicine 2006; 20: 159 • Morrison, R.S. & Meier, D.E., M.D. 2004, "Palliative Care", The New England journal of medicine, vol. 350, no. 25, pp. 2582-90. • Weeks, L.E., Macquarie, C. & Bryant on, O. 2008, "Hospice Palliative Care Volunteers: a Unique Care Link", Journal of palliative care, vol. 24, no. 2, pp. 85-93.
Editor's Notes
- I will also discusses the incident which happen in ward. A Patient of non-English speaking background and limited understanding of English was admitted in our ward with chest infection. She had been in hospital for two weeks and was planned for discharged in a few days as the patient was feeling better and improving overall. The patient’s family were also happy to take her home. The day before proposed discharge, the patient had a cardiac arrest in the toilet. Once patient found not breathing and cyanosed, the emergency alarm was activated and the medical emergency team (MET) team arrived. The NFR status of the patient was unknown so another nurse looked in notes to determine if she was NFR. Due to her age, there was a concern that she was NFR.The CPR was delayed by few minute in process to confirm the patient NFR status. Once confirmed that the patient was for resuscitation, CPR was commenced. The family was notified by the attending doctor during the process that she was not well and the patient was undergoing CPR. The patient was unable to be resuscitated. Seeing as the patient was for discharge next day and feeling lot better patient family could not understand why all of a sudden she became that unwell and passed away. Patient daughter was in hospital with her at 1700 hours and patient had arrest at1830 hours. In this particulate case, the patient’s daughter was so upset and she was not able to understand that mum was supposed to come home, was feeling lot better and how she died. Patient family suspected that we (nurses) do something wrong, given wrong medication or something else from nurses or doctor side went wrong. She demanded to read the nursing and medical notes and get copy of notes. She wanted to know all the events which lead to death. She was not convinced by telling that mum was sitting in toilet and had cardiac arrest. It became coroner case and every nurse involved in the care of particular patient was interviewed.
- Palliative care is multidisciplinary and its approach is focused both on the patient and their family. It encompasses the care of the patient and family during the progression to incurable illness, the advanced stages of disease and the last hours of life. It is based on the integration of medical and other holistic treatments Ventafridda, V.2006:159)
- The NFR order is one of the most important patient care directives that can be issued, seeing that it has dramatic and irreversible consequences. Resuscitation has the ability to reverse premature death, but it can also prolong terminal illness, increase the family's anxiety, and have serious economic consequences. Despite the desire to respect the patient’s autonomy, there are many reasons why withholding resuscitation maneuvers may complicate the management.
- Autonomy: The right of the patient to accept or refuse any treatment. Not malefiency: Doing no harm: or, even more appropriate, no further harm Beneficial Implies that health care providers must provide benefits in the best interest of the individual patient while balancing benefit and risks. Justice:Implies the concern and duty to distribute limited health resources equally within a society, and the decision of who gets what treatment (Santonocito,. C. 2013: 14–21).
- To reassure the family that ‘everything’ is being performed for the patient to maintain hope for the patient and family. Prevent patient suffering because of inappropriate CPR decision-making by a senior clinician. Provide the patient and family with illusory autonomy. Circumvent the patient and families’ unrealistic view of CPR. Circumvent the patients’ and families’ religious convictions. Redirect finite resources to more ‘salvageable’ patients. Limit expensive treatments by providing a successful exit from a devastating disease.
- Whats the prognosis of disease .patinet cultural and religious beilef ,mental status and do they want it for all future hospital admission or not this need to be addressed .proper written in medical notes and if possible elctronically enterd in system.Sign the form provided by NSW health and according to each hospital policy.
- With above condition NFR can be initied after discussing with family and treating team.howevere if patinet wish not want CPR regaredless of age and medical condition ,their wish need to be garnted.
- CPR .where active resusitation measure are done to revive the parson. Some patinet have NFR order where they want chest compression but no intubation or defribrilation.oxygen Via mask and injection can be given who have specific wish in cash or cardio pulmonary arrest.queanbeyan hopsital has another component with NFR that MET (medical emergency team ) need to be called or not in such case. If the doctor has speicifcially maintioned not to activate MET call than only we should avoid MET call otherwise we need to activate MET call.some doctor say just comfort care no observation as well,no anitibiotic and only pain relief which is specific to doctor and patinet . It does not apply to all NFR order.
- Patinet with chronic renal failure and other condition who have NFR order but they need bllod transfusion and total perntral nurtional which is not part of NFR so this all need to be done unless otherwise indicated or patinet wish not to have all these . NFR means not to do CPR if patinet suffer cardiac arrest . Rest all has to be done which can help patinet .
- Patinet value are most integral part of care regardless of NFR status . The DNR order reflects the patient's desire after full cardiopulmonary arrest. Correct interpretation of living wills and DNR orders is essential if patient safety and autonomy are to be preserved (Sulmasy, D. P., He, M. K., McAuley, R., & Ury, W. A 2008: 1817-1822). The patient's benefit is at the ethical centre of NFR order, and his/her wishes are crucial for understanding what is best for him/her. The family is often involved in the decision making of the critically ill patient. Family dynamics and medical/legal concerns most often affect decisions to obtain/write a DNR order for a critically ill patient. .
- Few other example include ,I would like to have the tracheostomy out now and to stop ventilation. I want no further transfusions. I want you to make me as well as possible so that I can get home for my daughter's 21st birthday before I die.
- NFR documentation can take many forms (eg, written bedside orders, wallet identification cards, identification bracelets, or predefined paper documents approved by the local hospital or health services. The ideal out-of-hospital NFR documentation is portable and can be carried on the person” even the European Resuscitation Council (ERC) guidelines are useful for the orientation of health care providers. However, what is stated in the guidelines is “suggested,” and the way to carry it out depends on the different cultures and beliefs (Loertscher, L., Reed, D. A., Bannon, M. P., & Mueller, P. S. 2010:4-9) Our hopital has desiganted NFR form which we use. It placed inpatinet clincial notes at beginging so in case of cardiac arrest it can be found easily .a copy can be given to patient family . The form has got light pink color on edge which make it easier to locate .
- Most commonly used one are Written in file with special designated NFR form.bedside information about NFR is too contarversial at this stage and further evidence need to show benefit .
- Obtained from nsw health NFR original form reference no, NH606510 09/2011.
- In rural hospital with limited doctor on site and GP ,VMO visiting there is always lack of time and NFR order need discussion with family and patient ,sometime this can no NFR order despite patinet wish. Some cultural background and happy to accept that their loved one has come to the end of life and they want to have peaceful and pain free death while some culture do not want to give up and have all possible tretement can be done for them . There is no system in place to place to have NFR for all elderly . Clinical think that variability in the interpretation of a NFR order occur due to multiple factors, including insufficient education, incomplete understanding of patient preferences, and lack of an appropriate tool for documenting patient goals of care (Fromme, E. K., Zive, D., Schmidt, T. A., Olszewski, E., & Tolle, S. W. 2012: 34-35)
- IV or Subcutaneous fluid can be given ,supplimeted Oxygen,indewling cathter and pain relife via syringer driver continus infusion or PRN can be adminsitred to relife the symptoms.pain relife patches like fentanyl also used .if patinet able to swllow perferbale meal is given or PEG feed
- Whenever patinet is admtted who is terminally ill refreral to paliative care can be a
- NSW health policy state that on each admission new NFR form need to be signed . If patient wish to change the NFR status its always neceassry to talk with patient and change in regards to CPR option. During surgery and anatehsia the patient who Pre operatively signed NFR need to be treted as another patient regardless of NFR status .Ambulance NSW has policy that other than palliative care all patient will receive CPR unless otherwise indicated.
- Caregiver and family provide care to a terminally ill member who has restricted social life, including reduced contact with friends and reduced participation in hobbies; stress from juggling family responsibilities. Caregiver and family need to understand the dying process and all comfort measure for patient. Additionally it’s really beneficial to know where to get help from like palliative care, oxygen supply or medical supply issue. Some patient who is on syringe driver their caregiver need to know about it so they make sure it working and take proper care while assisting for ADL(Weeks, L.E., Macquarie, C. & Bryanton, O. 2008:85-93)
- According to the World Health Organization (WHO), palliative care can be defined as active and total care measures that improve the life quality of patients with terminal diseases and their family/relatives, through prevention and suffering relieve by means of early identification, adequate evaluation, and treatment of pain and other physical, psychosocial and spiritual problems (Morrison, R.S. & Meier, D.E., M.D. 2004:2582-2590). Traditionally, medical care has been articulated as having two mutually exclusive goals: either to cure disease and prolong life or to provide comfort care. Palliative care is only initiated after life-prolonging treatment has been ineffectual and death is imminent. Patients would benefit most from care that included a combination of life-prolonging treatment (when possible and appropriate), palliation of symptoms, rehabilitation, and support for caregivers (Morrison, R.S. & Meier, D.E., M.D. 2004:2582-2590).
- Sometime patient family situation and self care ability is not the best and pain they suffer its better to have NFR and die peacefully. Once the patient quality of life is low and has got terminal illness where patient might not recover and it worth having CPR. In patient with Cancer where chance of survival is low is another option to have NFR. COPD patient who have multiple admission mostly opt out for NFR .