Saturday, January 29, 2011

Death Panels and "DNR"

Recently the term "death panel was used to described government's posture on end-of-life care.  Some authors have written government will withhold medical funding and restrict treatment our elder patients . They are strongly encouraging the use of the "DO NOT RESUSCITATE" (DNR) document to save health care dollars.  I have a different take on this than most.

The DNR is a legal document that states if your heart stops or you stop breathing you are not to be revived.   This seems reasonable to most who conjure the image an elderly brain dead person suffering on endless life support.  So why is this document a bad thing!

The flaw is the DNR document, in its current state, is often outdated and not specific to your condition at any given time.  Consider the case of the relatively healthy patient in a nursing home who chokes on a hot dog while playing Bingo.  That person may not be helped because of a DNR wrist band.  More often than not, decisions are made when it is impossible to determine the outcome.  The patient with Congestive Heart Failure may respond with  24 hours of respirator support and a shot of lasix ...........OR they may not.  Uncertainty is the rule; not the exception.

The DNR can become a legal and moral shield to provide a lower standard of care.  I cannot tell you how many times I have be confronted when I admitted a "DNR" patient into the intensive care unit.  The DNR is often a big "DO NOT ENTER" sign when it come to a higher level of care.  It is a guilt reliever for families and staff that have to make tough life and death decisions.  And it shields the conscience from the echoing self searching question, "Did I do the right thing". Unfortunately the DNR may put the patient further away from the nursing station (literally and metaphorically).
 
I am concerned with legislation that would label or categorize patients into an all or nothing level if care.  There is now government EMR requirements for hospitals to force a "DNR or No DNR" status at admission.  A bit too cut-and-dry for me. Time is needed for the patient and family to think about this in context of present state of health.  In the old days we had a poorly defined order called "comfort measures" . That meant withholding some aggressive interventions and giving patients treatment that would alleviate suffering even if it resulted in death.  This is not the same as Hospice care.  Hospice is palliative only. Patients receiving curative treatments would automatically dis-enroll patient from Hospice.  The physician must attest that the life expectancy of the Hospice patient is less that six months.  A better approach is combination or curative and palliative care depending on the current situation and tailored for the individual.

The most important advanced directive document is the health care proxy (HCP). In fact I would advocated that anyone that is 18 or older should have a health care proxy assigned.  I would love to see this become a requirement by DMV or medicare.  The health care proxy gives authority to someone you assign to make those decisions for you.  Why 18?  That is the legal age that a parent can no longer make legal decisions for a child who may be incapacitated.  This simple form can be downloaded from http://www.nylag.org/forms/Health_Care_Proxy_Form.pdf

In the older patient, a tool (such as polst) that assists in end of life decision making can be used to help communication between the patient, proxy and medical professional.  A copy should be part of their medical record. http://www.ohsu.edu/polst/programs/sample-forms.htm

Health care facilities should advocate the use of a health care proxy card and a more detailed end-of-life plan. Medicare has a "welcome to Medicare Visit" . Part of this visit is devoted to advanced care planning but there is not enough time for proper consultation.  I would propose that CMS covers a separate visit specifically dedicated to discuss and document end-of-life wishes. It should be a Quality Indicator encouraged by the HITECH stimulus and PQRI quality initiatives.

The Death Panel notion is far fetched and fodder for movies the likes of "Soylent Green".  But the concept of government promoting DNR orders for the purpose of cost containment, is a concern to some.