American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, June 20, 2013

A better POLST and informed consent for resuscitation

To resuscitate or not to resuscitate, that is the question. Whether 'tis nobler to beat the heck out of a person on his or her way out in the hope of saving his or her one precious life, or to allow death to proceed at its own pace with expectation of a peaceful passing.

The United States has come a long way in the last two decades since 1991 when the Patient Self-Determination Act was instituted. In most hospitals patients are asked what their wishes are regarding resuscitation and many states have instituted POLST (Physician's Orders for Life Sustaining Treatment) forms which spell out which interventions are acceptable to individual patients when they are very sick, things like blood transfusions, antibiotics, feeding by nasogastric or gastric tubes, intubation and ventilation and chest compressions and electrical cardioversion in the event of cardiac arrest. Theoretically we discuss these things with every patient when they come into the hospital, but we don't really do it very well which results in misunderstandings and needless misery.

When the patient is competent to discuss life sustaining treatments the conversation often goes like this:

Doctor: "What would you want done if your heart were to stop? Would you want us to do chest compressions and put a tube down your throat so we can support your breathing?"

Patient: (Why are they asking me this? Am I gonna die? Of course I want them to save me. My heart could stop right now! What about my grandkids?) "Sure, I'd like that. Just give it a try. But I don't want to be kept alive if I'm a vegetable."

Doctor: (I sure don't want to break all of this nice guy's ribs and traumatize his upper airway and, if we did get his heart started again, have him helpless in the ICU while we try to decide whether to put a feeding tube down and send him to a nursing home. With any luck he'll die in his sleep when he's not in the hospital.) "OK then. We'll put you down as full code. Just sign here."

I went online to see how other countries do this, and found that there is a great deal of variation. In many Middle Eastern countries resuscitation is performed on all hospitalized patients in the event of cardiac arrest, regardless of patient or family preference. In Australia there are many different policies which are different in different hospitals, and may or may not involve patient and family participation in decision making. In England the patient is involved in these discussions if he or she is competent, but if not, the doctor makes the decision, and if the family has an opinion this is taken into consideration but the doctor really has the final say.

I read an online discussion about an 86-year-old-nursing home resident in the UK with heart failure who was admitted to a hospital and suffered a cardiac arrest. He did not have cardiopulmonary resuscitation CPR due to a nurse thinking he had a do-not-resuscitate order, which he did not. After the event it was agreed that CPR would not likely have saved him, but it was the discussion after the article that was particularly interesting. About half of the people said that it was terrible that mistakes like this ended in a patient not getting life-saving CPR and that in many cases doctors made these decisions and "played God." The other half were people who said that they had seen CPR on old people and it was brutal and hardly ever worked.

Clearly doctors should not get to or have to "play God." Clearly, also, people who we ask to make these decisions, patients or families, usually don't know what we are really talking about when we ask them to make a decision about resuscitation ("code status.") Physicians are much less likely than our patients to request resuscitation in the event of cardiac arrest. I think our values are pretty much the same as those of our patients, we just know more about what cardiopulmonary resuscitation and its aftermath really look like.

So here is a good solution that preserves the autonomy of the patient while allowing the physician to do his or her job, which is taking care of the patient while following our Hippocratic Oath to "do no harm".

CPR, intubation and ventilation are medical procedures, just like a tonsillectomy or a hip replacement. There are expected risks and benefits. The risks are not insignificant and the magnitude of the expected benefits vary with each patient. If a patient really wants CPR, he or she or a surrogate decision maker should sign a consent form (well in advance of experiencing a cardiac arrest) which includes risks and benefits. The benefits, of course, would be to live and recover enough to be able to leave the hospital. In the least complex patient, 1 in 5 of those who have a heart event which requires CPR can be expected to survive to hospital discharge. In the most complex, the expectation is 1 in 20 or less. The risks include, but are not limited to: pain; broken ribs; punctured lungs; trauma to mouth, teeth and upper airway; aspiration pneumonia; loss of brain function; multi-organ failure, prolonged dependence on caregivers including being confined to nursing home; monetary expense, and all the usual complications of prolonged intensive care unit and hospital stays. Also, should we not be successful, loss of the opportunity to die in peace.

Presently our POLST forms say none of that. Different states have different forms, but I have been involved in completing ones in California, Oregon, Idaho and Washington and they share similarities. They start with a check box for CPR or DNR. Then there are other boxes specifying the general level of interventions, including comfort care (giving only treatments that provide comfort without attempt to prolong life), limited interventions (lengthen life, but generally not in an intensive care setting and not using advanced life support techniques) and full treatment (everything, dialysis, ventilator, electrical cardioversion, the works.) Then there may be questions about whether artificial nutrition by IV or tube is acceptable, whether blood products are OK, whether antibiotics should be used. It is really hard for a patient or family to get through all of these questions, and many of them are too complex for a person without healthcare experience to understand. Still, they are a good starting point for discussion.

In general the patients who I talk to just want me, as the doctor, to make the right decisions at the right time that are most likely to get them what they want. Most of them want as much good life as possible, the relief of whatever discomfort or disease brought them in, and to have this done as quickly and economically as possible so they can go home. We have no box for this on the POLST form.

I would propose that we should add this box, up at the top, as an alternative to "CPR" vs "DNR." I would propose that the choice be called "Resuscitation at the discretion of physician, guided by my goals of care." This would allow a nuanced decision about resuscitation--from none at all if the patient had been declining and not responding to treatment and was found unresponsive and pulseless (a situation which almost never results in success) to full resuscitation for a witnessed collapse with ventricular fibrillation in a patient who had a pretty good level of function.

This does, however, require another piece of paper, which I think should be part of any patient's admission to the hospital, and probably part of the chart at the primary care doctor's office. This would be "goals of care." There was an article in the New England Journal of Medicine last year that talked about altering our ideas of success in medical care to reflect how well we helped a patient achieve their goals rather than focusing on specific markers of disease control. Some patients value not being dizzy and not taking a bunch of expensive pills more than they value good blood pressure control, for instance.

I think it is important to know, at the time of hospitalization, what a patient really wants. Do they really need to be discharged by a certain date or time? Do they have lousy insurance and need their care to be as thrifty as possible? Do they really value pain control, or sleep at night, or making sure to have a certain meal on time? Do they need quiet, or visitors? Do they want to avoid antibiotics or medications that can cloud their thinking? Do they think that spending time in a nursing home would be OK? Are they hoping to die in the hospital because their burden of disease is becoming intolerable? Do they want to make it home for Christmas or live until a grandbaby is born? We don't ask these questions and we should, or at least somebody should.

If a person chooses "CPR" or "RDP" (resuscitation at the discretion of physician) they, or their surrogate, really need to read and sign the informed consent form for resuscitation, because they do need to know what this means.

I hate filling out forms, but if they help focus treatment so it is more appropriate and if they help me understand my patients and communicate with them more effectively, I'm OK with that.

So, the bottom line: In order to have patients make better decisions about resuscitation, we need to share more information with them and allow them to depend on our clinical judgment to help them have the outcomes they really want. To do this we should: first add a box to the POLST form that specifies "resuscitation at the discretion of physician" as an alternative to "CPR" or "DNR". Second, we should create an informed consent for resuscitation which makes clear expected risks and benefits and have everyone who wants resuscitation sign it. Third, we should make sure that patients are asked about their goals of care at the time of admission to the hospital and that physicians read them and honor them as much as is practical. Fourth, for those unable to complete a POLST form or give informed consent for resuscitation, physicians should make the decision about whether to resuscitate based on most patients' goals of care and good clinical judgment. This is, after all, what we would do for such a patient with any other procedure that we perform in the hospital.

Janice Boughton, MD, FACP, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

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Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

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David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

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Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

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Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

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The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

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Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

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Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

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PLoS Blog
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White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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