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A novel approach to end-of-life care

May 2015
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Published in the May 2015 issue of Today’s Hospitalist

YOUR HOSPITALIZED PATIENT, who has a DNR, suddenly has difficulty breathing. But chances are, those needs won’t be addressed urgently because clinicians often equate “DNR” with “do not treat.” Yet that patient’s suffering deserves as urgent a response as those who choose aggressive end-of-life (EOL) care, say the developers of a new initiative at Novant Health, which is based in Winston-Salem, N.C.

They call their solution Code Comfort, an emergent response for patients with a DNR order who want comfort measures and experience a symptom crisis at end of life.

“Staff often feel at a loss to know how to respond to those patients experiencing acute problems with breathing, pain or anxiety toward the end of life because the typical treatment would be aggressive invasive interventions,” says Melissa P. Phipps, JD, Novant Health’s vice president of patient services. “Often, the response is to either do everything or do nothing.”

Developed as part of an across-the-board focus on end-of-life issues, the pilot initiative was rolled out a year ago at Thomasville Medical Center in Thomasville, N.C.

But it hasn’t been easy or quick to implement. In fact, this freshman year has been spent developing education around how limited a DNR order alone is in terms of understanding patients’ wishes. Without asking patients additional questions, providers won’t know if those with DNRs want other aggressive care besides CPR or wish only for comfort measures.

Developers have also wrestled with hospital policies and EMR templates that can trip up what Ms. Phipps calls a “novel approach” to inpatient EOL care.

As proof that the time spent building awareness has paid off, consider this: The code has never been called since the initiative took effect. While the pilot involved only a small number of patients, the initiative team is hopeful that clinicians’ increased awareness and proactive management of these patients has reduced the risk of a crisis.

“We consider it a success,” says Melanie Kelly, Novant Health’s corporate director for palliative care, “if it’s implemented very little.”

How it works
According to the Code Comfort algorithm, the hospitalist starts by determining what a patient truly wants, exploring with patients and their families their wishes regarding other possible treatments besides not wanting CPR.

“If you automatically make every patient with a DNR order a Code Comfort, you’re not asking patients what they want,” Ms. Phipps points out.

Instead, hospitalists use a portable medical order such as MOST (medical orders for scope of treatment) or POLST (physician orders for life-sustaining treatment) that ask additional questions regarding scope of care. When a patient declines CPR, “take the questioning to the next level,” says Ms. Phipps. “Ask, ‘If other problems arise, do you want full interventions? If you’re in the ICU, should we do everything short of CPR? What about limited interventions?’ ”

Patients choosing limited interventions may be appropriate for Code Comfort at the hospitalist’s discretion. However, standing orders for Code Comfort should be entered solely for patients choosing comfort measures only. The code includes an order set with medications that nurses can use to aggressively manage pain, dyspnea and agitation in an emergency.

“It’s like a hospice kit but for an acute care setting,” Ms. Kelly says. The set includes medications such as morphine, fentanyl and haloperidol.

When Code Comfort is fully implemented, patients and families will receive information explaining the code. “We are committed to making sure patients don’t suffer while honoring their request not to receive life-prolonging measures,” Ms. Phipps says.

Nurses can activate the code using an overhead page. Staff who may respond immediately include palliative care physicians, nurses, respiratory therapists and chaplains.

A shift in perspective
By talking to providers, Ms. Phipps says, the initiative team quickly realized that they had to invest the time in education because staff are not accustomed to finding urgent options for patients with DNRs.

“You can’t skip the educational piece,” she says. “It doesn’t work if you just roll such an initiative out without the training.”

Each hospitalist, as well as some nurses, attended a training session, which included interactive case studies based on real examples. One case, for instance, considered a patient with a DNR and difficulty breathing. Questions to consider include: Do we intubate if the patient hasn’t made her preference known? Why might she want “or not want “intubation?

“The model has helped providers understand that we need to go deeper in our conversations with patients and families,” Ms. Phipps says.

The educational effort isn’t over. The hospitalist program is planning to train its members in how to translate care goals into treatment goals. “The hospitalists are still all over the place in their understanding,” Ms. Kelly points out. “Some think, ‘I don’t admit patients with a DNR order to the ICU.’ ”

And while the program initially focused on hospitalists, the team wants to expand its educational efforts to include all nurses, ICU physicians, pulmonologists and other specialties.

Lessons learned
Initiative leaders found that not all nurses were comfortable administering some of the medications in the Code Comfort order set. They are incorporating those issues into the educational process.

They also are reviewing current policies to ensure that nurses can carry out Code Comfort orders. While patients on palliative care or hospice units or in the ICU can receive the medications included in the Code Comfort order set, for example, policies on other floors may prohibit that administration.

Additionally, team leaders are working to modify the electronic medical record. The system currently asks only if a patient does or doesn’t want CPR, but not if the patient wants full or limited interventions or comfort measures only. A customized version will not only ask those questions, but populate for Code Comfort if “comfort measures only” is selected. Before the electronic updates can be made, however, clinical staff need to know how to best respond to those patients who choose “limited interventions.”

Novant Health also plans to expand the initiative’s reach. It will be implemented next at Prince William Medical Center and Haymarket Medical Center, both in Virginia. The plan is to then roll it out in the hospice and palliative care units at Forsyth Medical Center and Presbyterian Medical Center, both in North Carolina.

Ultimately, Novant Health wants to provide the Code Comfort option to all inpatients who have a DNR order and choose comfort measures only. They are also considering whether patients need a Code Comfort bracelet. Currently, Novant Health patients wear purple bracelets when they have a DNR.

And because the system hasn’t actually had a code called, team leaders are running mock ones before they roll out the program at other hospitals.
“The lesson we learned is that this is more than a new order set and process,” says Ms. Kelly. “It’s about changing culture.”

Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.

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