DNR and Patient Advocacy
Ashleigh Lesko, RN, BSN
Western Governors University
Table of Contents
Chapter 1: Introduction…………………………………………………………………………….. 3 Problem Statement………………………………………………………………….……3 Problem Background…………………………………………………………………….3 Practice Change, Quality Improvement , or Innovation…………………………………5 Rationale for the Practice Change, Quality Improvement, or Innovation……………….6
Chapter 2: Review of the Literature……………………………………………………..7
Best Practices……………………………………………………………………………7
Evidence Summary………………………………………………………………………8
Recommended Practice Change, Quality Improvement, or Innovation………………..13
References………………………………………………………………………………15
Chapter 1: Introduction of the Problem
Introduction
Problem statement
The problem observed within Jersey Shore University Medical Center is the lack of proper documentation and lack of the proper nursing interventions for a patient who wishes to be a DNR. Knowledge between the nursing staff of Jersey Shore University Medical Center regarding DNR status needs to improve to in turn improve patient advocation. The nursing staff are not properly adhering to the code status of the patients and are not properly assisting patients with their right to obtain and follow a DNR order.
Problem Background
Jersey Shore University Medical Center is the regional trauma center located in the heart of Neptune, New Jersey. The organization is a Magnet recognized hospital employing nearly 3000 employees. The staff members of Jersey Shore University Medical care for a diverse population of acute care patients. This population includes patients aging for newborn (hours old) to 100 plus years old, encompassing death and dying, end of life stages. The hospital offers specialties including, emergency, trauma, pediatrics, maternity, neonatology, telemetry, critical care, and medical surgical units. Being that the hospital serves a diverse population of all age groups and acuity levels, DNR orders and code statuses are often used within the acute care setting.
Throughout observation of Jersey Shore a problem has arisen regarding DNR and patient advocation. It has been observed that DNR orders are not always followed as per the patients’ wishes. The documentation surrounding DNR orders is poor and lacking within the organization. This is due to multiple factors within the hospital.
First reason observed for lack of DNR compliance revolves around family presence during code or critical situations. Often times the patients have already chosen their code status prior to losing capacity to make their medical decisions. Families have been observed overturning a DNR order or rescinding the DNR status as a patient begins to deteriorate. This has been observed in families that have expressed high concern or emotion regarding their loved one and their care. It has also been observed that the families are in denial regarding either the patients’ status or their ability to recuperate from their condition. Also some families that are well educated on the patient’s condition and are aware of the outcomes of the situation, lose control and emotional stability during code situations. It has been observed that during this loss of emotional stability, family members rescind the patient’s wish to be a DNR.
The second reason observed for lack of DNR compliance among the nursing staff includes the high energy of the moment during a code situation. It has been observed within the organization that the nursing staff are highly emotional. They have been observed providing patient centered care during all aspects of care, but during the code situations the nursing staff have been observed with extreme energy. Many nurses, other than just the primary nurse, come into the room. They begin hooking the patient up to monitors and begin hanging medications rapidly. It has been observed during a code blue situation that a nurse runs into the room and immediately begins cardiopulmonary resuscitation (CPR) without understanding the patients code status. This can be attributed to the organizations lack of DNR patient bands or the lack of DNR patient stickers on the patient’s chart. It can also be attributed to the lack of differentiation between telemetry strips on a DNR patient versus a patient whom has designated a status of full code. It has been observed that a nurse identifies a lethal cardiac rhythm on the telemetry monitor and immediately runs into the patient’s room and begins CPR on a patient that is a full code.
Finally, it has been observed that there is a lack of DNR documentation within the patient’s chart. It has been observed that many of the patients’ charts lack any order of code status. This means there is no specification on whether the patient would like a CPR during a cardiac or respiratory arrest. This has left the nursing staff blind during a code situation. It has been observed within the organization that the patients will automatically receive CPR if they have no specific code status order. It has also been observed that patients have advanced directives or living wills but do not present them to the nursing staff within the organization. It has been observed that the patients are either unaware of where the advanced directive lies or they are unable to have a family member bring it in during their stay. They patients have also been observed to be under educated on the meaning of a DNR order versus a full code.
Practice Change, Quality Improvement, or Innovation
In order for Jersey Shore University Medical Center to increase their adherence to a patient’s wish regarding a DNR order, a practice and quality improvement will need to be put into place. This includes nursing staff being educated on the DNR policy via an e-learning module. This e-learning module will allow the nursing staff to be educated on the proper initiation of a DNR within the institution. It will also present the nursing staff members with problem solving techniques to deescalate situations with family members who may try to rescind a DNR order or those who are not willing to respect the patients’ wishes.
The implementation of color coded telemetry strips for DNR patients will be included to highlight those patients who wish to be a DNR. The use of DNR patient bands and DNR patient chart stickers will also be implemented in the organization. These new implementations will be to ensure patient centered care is being practiced within the hospital and to spark a quality improvement surrounding the particular problem addressed within Jersey Shore University Medical Center.
Rationale for the Practice Change, Quality Improvement, or Innovation
By allowing for a policy change regarding DNR orders and patient advocacy within Jersey Shore University Medical Center, patient safety, patient outcomes and patient satisfaction will improve. By implementing the need for staff education regarding proper documentation of a DNR order, patient advocation will improve. Documentation of the patient’s wishes will become more clear and easier to follow for the nursing staff. Allowing the DNR order to be documented in multiple different ways within the patient’s chart will help to ensure the patient’s wishes are properly carried out by the nursing staff. Patients will feel more comfortable in expressing their wishes to the medical personnel. Patients will be able to gain a trusting relationship with the staff in the organization which will also improve patients satisfaction. The policy change will also help to reduce mistakes related to improper documentation of DNR orders. This will improve patient safety and patient satisfaction. Staff education related to DNR orders and patient advocacy will improve patient safety by ensuring CPR is being administered to the proper patients in the proper situations. Patient outcomes will also improve as the patient’s code status will be properly documented for all staff members within the institution to follow. The use of evidence based practice will ensure that the information and policy changes are best practices. The evidence based practice will drive the policy change to improve patient safety, patient satisfaction and patient outcomes within Jersey Shore University Medical Center.
Chapter 2: Review of the Literature
Best Practices
The literature review of 30 credible sources revealed that DNR and patient advocation has been studied throughout many acute care settings. Throughout this research there a multiple best practices when discussing DNR and patient advocation. These best practices include the need for early development and intervention of a DNR order, the need for proper education for the staff members, the need to respect a patient’s autonomy regarding their choices in their care, and the need to develop patient-centered care regarding DNR and code status.
The need for early intervention and early development of a DNR order within the acute care setting is considered a best practice. Proactively communicating with patients about their wishes regarding end of life care helps to prevent patient dissatisfaction. CPR and resuscitation efforts can be destructive on a patient’s body. Often times ribs are broken in the process of CPR and patients wake up in excruciating pain. This can be extremely disheartening for a patient who wished to be a DNR. By ensuring the patients’ wishes are documented immediately upon their arrival to the organization, these experiences can be eliminated, in turn improving patient satisfaction. The use of DNR orders can also reduce the cost of unnecessary medical intervention for both the patients and the hospitals.
Staff education is also observed as a best practice when looking at DNR orders and patient advocation. Ensuring staff members are properly educated on the need for DNR orders is important. Education will help the staff members to understand the need for the order and its purpose within the organization. The staff will also be able to properly educate patients on their code status during their hospital stay. This education will help to ensure the DNR orders are properly documented within the patients chart, as well. Education surrounding DNR orders can also include ways to properly communicate with patients and family members regarding DNR orders. This includes therapeutic communication to facilitate an open discussion surrounding the patient’s wishes.
Patient autonomy is considered to be another best practice among the literature. Patients have the independence to express their concerns and their wishes upon entering the hospital. Healthcare professionals must respect a patients autonomy and listen to their wishes. These wishes should be incorporated into the patients medical care. Allowing the patients to participate in their own care also helps to improve patient satisfaction. No decision regarding a code status order should be made without the patient as long a the patient is healthy and able to participate in their care. Assigning a code status to a patient upon arrival to the acute care setting is not beneficial for the patient or the organization. This practice lacks the right for patient autonomy.
Finally, patient-centered care, especially involving a DNR order and a patient’s code status, is considered a best practice. Involving patients and family members in their care helps to improve patient safety, satisfaction and outcomes. The patients and family members should be the primary drivers of their own medical care. The healthcare professionals again need to respect the patient’s wishes and always be sure to involve the patients in the decision making process. This is true as well for DNR and code status orders. Patients drive these orders and should be the center of any code status discussion.
Evidence Summary
A literature review of 30 credible, peer reviewed sources within the last five years has been completed. There were a few main themes regarding DNR and patient advocation that were discovered. These main ideas include the need for early intervention, the need to staff education, decisions related to patient autonomy, and patient-centered care.
Early intervention
The first idea that was found throughout the literature review was the idea and need for early intervention regarding DNR orders. Ang, Zhang, and Lim (2016) discussed the “importance of early planning for end-of-life care. This must be initiated proactively by healthcare professionals to engage patients in a culturally sensitive manner to discuss their preferences, in order to facilitate open communication between the patient and family” (p. 22). Baek, Chang, Byun, Han, and Heo (2017) also stated that, “earlier attainment of DNR permission was associated with reduced use of medical intervention. Thus, physicians should discuss death with terminal cancer patients at the earliest practical time to prevent unnecessary and uncomfortable procedures and reduce health care costs” (p. 502).
According to Caissie, Kevork, Hannon, Le, and Zimmermann (2014), “Evidence suggests that patients are receptive to discussions about code status and other advance directives on admission to hospital [26, 27], and that code status discussions at admission do not affect patient or surrogate satisfaction with care” (p. 378). According to Mills et. al. (2017), “fewer resuscitation orders were written at admission for older adults than might be expected if goals of care and resuscitation outcome are considered” (p.32).
Finally, Hing, Chin, Ping, Peng, and Kun (2016) stated that ACP [Advanced Care Planning] discussions enhance patient's autonomy, focus on patient's values and treatment preferences, and promote patient-centered care. As mentioned by Lee, Ong, Thong, and Ng (2018), end of life discussions and decisions need to take place in a more timely manner in order to improve patient care (p. 17).
Staff Education
The second idea noted throughout the review of the literature includes the need for education amongst the staff. Baumann, Killebrew, Zimnicki, and Balint (2017) spoke about the need for education by stating, “health care professionals…may be unfamiliar with the guidelines and unsure of their role in reevaluating a DNR order” (p. 20). Bennett, Lovan, Hager, Canonica, and Taylor (2018) discussed the importance that brief education can have on patient preferences and needs when it comes to end of life situations (p.99).
This education can also help to reeducate staff members on the need to follow the patients’ wishes. Downey, Au, Curtis, Engelberg (2013) stated that “in most cases, clinicians believed that their patient would want MV [Mechanical Ventilation] or CPR if needed” (p. 16). According to Punjani (2013), “One of the best tools which healthcare professionals particularly nurses count on in these challenging situations is the ethical decision making process.” which can be reinforced within required education (p. 27). According to Rolland (2017), “formal education, including the elements of end-of-life care in curriculum, is essential to effectively and efficiently transition from the curative care role to the end-of-life care role” (p. 18).
Finally, Einstein, Einstein, and Mathew (2015) state that staff members “are unlikely to discuss prognosis or offer recommendations on CPR in treatment-refractory cancer principally because of a conflict with their concept of patient autonomy” (p.535). As stated by Mills, Rhoads, and Curtis (2016), students often feel underprepared and lack the confidence to speak with patients regarding their code status and preferences regarding end of life care (p. 323).
Odgers (2018) discusses the need to education and training among health care professionals by stating, “end of life care planning in acute hospitals needs to incorporate strategies, such as health professional communication skills training and advance care planning, to ensure end of life discussions take place” (p. 30). By educating the staff members on ways to speak to patients regarding code status and end of life treatments, both the staffs’ confidence and the patients’ confidence improves.
Patient Autonomy
The need for patient autonomy and ethical decisions was the third idea spread throughout the literature. Braddock and Clark (2014) reinforced that the “Patient Self Determination Act of 1991,…requires hospitals to respect the adult patient’s right to make an advanced care directive and clarify wishes for end-of-life care.”
Bressler and Popp (2018) speak to the importance for patient autonomy by reinforcing the need and “importance of patient-centered and individualized end-of-life care” within the acute care setting for all patients (p. 43). A good example of patient autumn was portrayed by Collier, Kelsberg, Safranek, and Neher (2018) “Most patients (91%-100%) who select “do not resuscitate” (DNR) on their physician’s orders for life- sustaining treatment (POLST) forms are allowed a natural death without attempted CPR across a variety of settings” (p.249). On a negative aspect, according to Downar et al. (2013) in the acute care setting” patients are typically “full resuscitation” by default unless a “do not resuscitate” (DNR) order is written” (p.499).
With that being stated, Hawryluck, Oczkowski, and Handelmanstated (2016) stated “a decision regarding a no-CPR order cannot be made unilaterally by the physician” (p.975). This shows the need to patient autonomy in the decision. As stated by Powell and Hulkower (2017) “individual autonomy has led… to the view that competent adults should decide for themselves how they are treated medically” (p. 29).
Finally, by allowing patient autonomy trusting relationships between staff members and patients are built. According to Rady and Verheijde (2016), “high-quality scientific evidence, absence of harm, and respect of patients’ values and preferences are hallmarks of trustworthy recommendations” (p. 350). According to Shih et al. (2015) “communication between patients and physicians about end-of-life care should be enhanced to ensure that decision making is based on patients’ preferences” (p. 629).
Patient-Centered Care
The final theme that was noticed within the literature was the need for hospitals to provide patient-centered care. According to the Joint Commission (2015), staff members “who honor, implement and facilitate the patient’s advance directives, and respect what matters to the patient” will improve patient-centered care and patient safety within the acute care setting (p.3). According to Hartog (2014), the finding within the study showed that patients with advanced directives more often had a designated code status. This code status designation had little to no influence on other treatment options or hospital care (p.131). High quality, patient-centered care was provided even though the patient chooses to be a DNR. Higginson (2017) harped on the importance in evaluating “the needs and preferences of patients and their families… when assessing the quality of end of life care” (p.12). Salins et al. (2018) spoke about the need to involve patients in the decision making process regarding DNR wishes by stating, “support and encourage patients to be involved, as far as they want to and are able, in decisions about their treatment and care” (p. 59).
Patient-centered care helps the patients to be involved with their care and medical decision. According to Hong et al. (2016) “results suggested that the use of advance directive promote patient participation in EOL [end of life] discussion” (p. 753). According to Howard et al. (2017), “understanding how a patient prioritizes his/her values, may then allow the clinician to guide the patient to further prioritize decision options if they are faced with decisions whose outcomes will not align with all of their values” (p. 6). As stated by Russell (2018), “Eliciting patient preferences of care relies on patient provider discussions and shared understanding of end- of-life treatment options” (p. 48). According to Livelo, Jurado, Hunt, and Mintzer (2018), “by respecting patients’ wishes, [and by] doing what is best for the patient” patient-centered care and culturally competent care improves (p. 14).
Recommended Practice Change, Quality Improvement, or Innovation
Based on the literature review and organization observations, practice change is needed regarding DNR and patient advocation within the hospital. This practice change will begin with a protocol driven change to improve and incorporate the best practices highlighted above within the organization.
This practice change will include the incorporation of proper documentation and signing of DNR orders by physicians within the organization. The physicians will be required to properly obtain a DNR order with the patient, ensuring the patient autonomy is respected and patient-centered care techniques are observed. The orders must also be properly documented. The physicians will also be encouraged to obtain this order swiftly, preferably as the patient is admitted to the organization. This helps to incorporate early intervention within the organization while respecting a patient’s autonomy to make their decisions. It also helps to improve patient-centered care within the organization.
The nurse educators will also be involved with the practice care for quality improvement. The next change will involve improving DNR documentation. Upon a patient receiving telemetry orders, those patients who are considered to be DNR’s will be designated a red color on the telemetry monitors. This red coloring will be the designated color for patients who are a DNR on telemetry. Those patients who are not a DNR will be color coded green.
Those patients who are a DNR will also receive DNR stickers on the outside spine of the charts and DNR bracelets on their wrists. This will encourage easy observation of DNR orders and will discouraged mistakes among the staff members.
The staff nurses will also be involved in this practice change. They will be required to complete e-learning education on DNR and patient advocation. This e-learning education will review the protocol and also highlight the nurses’ responsibility regarding DNR orders. They will also be educated on ways to therapeutically communicate with patients and family members. The physicians will also go through education regarding proper DNR documentation and will need to sign paperwork stating they understand the education. This helps to incorporate staff education into the organization.