Thunder Bay hospital talks resuscitation options with patients

White Coat Black Art27:29Revisiting the Do Not Resuscitate Discussion

We revisit a program about how health care workers and families grapple with Do Not Resuscitate Orders or DNRs. The show recently won the 2012 media award from the Registered Nurses Association of Ontario for Exceptional Reporting on a nursing issue.

Thunder Bay Regional Health Sciences Centre has unveiled a new system to help patients decide what level of resuscitation they would want in a life-or-death situation.

A new policy, announced at the hospital onMonday, requires hospital physicians to discuss five "code status" levels with their patients within24 hours of admission.

It was something Jan Miller said she never thought about when she was diagnosed with leukemia seven years ago.

When she found herself in hospital, she realized she hadn't talked to her family about what she would want if her heart or lungs stopped working.

"I didn't think it was necessary to have these discussions... nor did I know what the options were."

Miller who has since recovered, and is doing well is now a volunteer patient and family advisorat the hospital and was part of the working group that came up with the new Code Status Level policy.

She said it is essential for people to talk to their family members about the level of resuscitation they would want in the event of cardiac or respiratory arrest.

"Those are not always easy conversations to have, but is so important in order to ensure that your wishes are known, especially in the event that you are not able to communicate those preferences in hospital."

Balancing responsibilities with possibilities

Critical care physicianWilliam Anderson has worked in intensive care at Thunder Bay Regional for more than a decade. Hesaid the previously-used term "Do Not Attempt Resuscitation" is too vague.

"In the past there's been this artificial dichotomy, he said.

Anderson said in actual clinical practice, there are five levels of intervention ranging from full CPR and intubation, to palliative care.

For example, Anderson said,a patient with chronic heart failuremight choose a level in the middle and consent to breathing assistance from a mask, but not intubation.

"Maybe they've been intubated [before], they've been in the ICU and they don't want that again, Anderson said.

"Our responsibility is to provide the best possible care within the bounds of what the patient would want and what is medically appropriate.

We want our patients and their families to understand the options and the possible outcomes so that they can make informed decisions about their healthcare.

Levels of resuscitation

Source: Thunder Bay Regional Health Sciences Centre

Patients or their substitute decision maker will be asked to choose one of the following code status levels, which will identify the level of resuscitation that will be provided in the event of cardiac/respiratory arrest or clinical deterioration.

• Level 5: I want all medically appropriate life-sustaining measures.
• Level 4: I do not want Cardiopulmonary resuscitation (CPR), but I will accept a medically appropriate trial of intubation and mechanical ventilation including life support.
• Level 3: I do not want CPR. I will accept a medically appropriate trial of non-invasive ventilation including life support.
• Level 2: I do not want CPR or ventilator support but I want full medical therapy as appropriate
• Level 1: I want comfort measures only. I do not want CPR or ventilation. I do not want aggressive medical care. I do not want any prolongation of my life. I want treatment to provide relief of any pain or discomfort I may have.

For patients who are Code Status Level 4 or 3, a blue armband that clearly displays Level 4 or Level 3 will be applied. For patients with a Code Status Level 2 or 1, a purple armband that clearly displays Level 2 or Level 1 will be applied. This ensures that the patient's resuscitation wishes are communicated to all members of the healthcare team.