DO-NOT-RESUSCITATE DOES NOT MEAN DO-NOT-CARE: A QUALITY IMPROVEMENT INITIATIVE

Abstract

SESSION TITLE: Palliative Care and End-of-Life Issues Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Problem: The code status “do-not-resuscitate” (DNR) is discordantly interpreted amongst health care providers Background: DNR is defined as an advanced care directive to decline cardiopulmonary resuscitation in the event of a cardiac or pulmonary arrest [1] Varying institutions may prefer synonymous terms such as “allow natural death” which are usually defined in core policies However, DNR is frequently misconstrued and is associated with less active treatment or escalation of care as well as basic therapies [2] METHODS: An anonymous survey was conducted on internal medicine residents at a large urban hospital in Florida where DNR is defined as above Four single-sentence hypothetical questions were designed, simulating plausible scenarios of deteriorating DNR patients, prior to cardiopulmonary arrest Answer options consistently reflected no active treatment/escalation of care (A) vs an ideal escalation (B) vs uncertainty (C) In each sequential scenario, the escalation of care option was more aggressive or invasive After a target of 40 responses, a 5-minute virtual presentation of the institution’s DNR policy was done and the same survey was conducted again RESULTS: On the initial survey questions (Q), the percent of physicians choosing the option to NOT actively treat or escalate care (A), was as follows: (Q1) 15%, (Q2) 23%, (Q3) 38% and (Q4) 50% This represented an unsettling discordance not only amongst different physicians but also demonstrated that a single respondent became less likely to escalate care (B) as it became more aggressive or invasive in subsequent questions Furthermore, most respondents were certain of their answer as the average uncertainty rate was 9% On the post-intervention survey, the option to NOT actively treat or escalate care (A) was chosen as follows: (Q1) 6%, (Q2) 6%, (Q3) 15% and (Q4) 41% There was reduced overall discordance and a reduced average uncertainty rate of 3%, yet, there was still a noteworthy proportion of physicians electing to NOT escalate care CONCLUSIONS: The code status DNR has discordant interpretations and applications amongst physicians, even within the same institution This dyssynchrony alludes to a broader ambiguity regarding end-of-life or goals-of-care decisions A brief virtual education simply defining the code status for the institution is a step toward attaining an accord, but additional means may still be necessary Further interventions may include in-person focus groups or utilising the electronic medical system to create a more defined order set for physicians involved in these decisions CLINICAL IMPLICATIONS: Harmonising the interpretation of DNR orders within an institution is critical from both a patient safety and litigious perspective This is a timely issue especially with the advent of incoming interns, rising seniors and physicians transitioning into new roles or institutions, all in the milieu of COVID-19 DISCLOSURES: No relevant relationships by William Kogler, source=Web Response No relevant relationships by Michael Omar, source=Web Response No relevant relationships by Hamel Patel, source=Web Response No relevant relationships by Vandana Seeram, source=Web Response