 will be Dr. Robert Taylor. Dr. Taylor is an associate professor of neurology and internal medicine at the Ohio State University College of Medicine. Bob was the founding medical director of the Center for Palliative Care at the Ohio State Wexner Medical Center where he currently co-chairs the ethics committee, as well as serving as the chief of staff of the OSU James Cancer Hospital. Today Bob Taylor will talk to us about improving DNR discussions, a categorical approach. Bob. Thank you Mark and thank you to the Center. I was in the class of 93 so this is about a little more than 20 years since I was here and the beginning of this thought process that led to this presentation really started during that time at this program. Ellen Fox taught of course concepts in clinical ethics or topics in clinical ethics which is where I read one of the few of the papers that started this discussion or the thought process and then in addition John Lantos talked about we he and I worked on a futility paper and then others in the faculty and in the group contributed to thoughts that eventually led to this this process so oops going the wrong way let's try this okay that's where I'm gonna end that's where I'm going all right so this these are my objectives so to discuss the appropriateness of stratifying patients according to three broad medical categories based on likely outcomes of resuscitation and then explain why DNR discussions should be framed differently depending on which of the three categories the patient is in. So unfortunately none of us live forever so we all are going to die at some time in the foreseeable future and this should inform our thoughts about this problem. This is probably I'm pretty sure this paper was discussed in Ellen's course. Blackhall, Lizzie Blackhall must we always use CPR New England Journal article 1987 and many of you are aware of this article and she raised the question as to is this idea that we always offer CPR to everybody appropriate and there have been many many people who've written on this topic subsequently and I think they are all on to something I think that I'm hoping that I have an approach that helps make this less of a problem to see what people think so this is the probably the paper that sort of got me to finally sort of frame things the way that I do in this paper this presentation so you are at all an MD Anderson looked at outcomes from cardiac arrest and they 244 large number looked at what they called anticipated arrest and sudden arrest and anticipated arrest in this paper was people who were in the hospital MD Anderson where everybody taking care of them the doctors and all thought that this patient was going to arrest for one reason or another they were still full code and they were all therefore coded the sudden arrest were people who were not expected to die during that admission and suddenly had an arrest unexpectedly and of course they were all resuscitated and you can see that the outcome is quite different so on the side where the was sudden unexpected arrest approximately 20% survived to leave the hospital and that's consistent with general expectations throughout the country on the other side where the anticipated arrest or where arrest was anticipated there actually were a percentage about 10% who recovered from the original arrest but nonetheless zero of those patients survived to leave the hospital so 0% survival to leave the hospital when the arrest was anticipated so this is an important number even these numbers are strikingly different large number of and zero versus 20% but somehow these statistics don't help us in general and I'm going to come talk about why that is or what an alternative approach is so this is a paper that was published in supportive oncology rejected by multiple other other journals first but ended up in supportive oncology myself a colleague who's a powder care physician Jillian Guston and Dr. Wells Dugugorio who's a psychologist that works in our powder care program and we came up with this paradigm of trying to categorize people into these three groups which I don't think will surprise anybody the basically healthy advanced or chronic illness in the imminently dying I'm going to give you some just quick examples of each of these cases so case one would be the basically healthy person so a healthy 45-year-old woman admitted to our hospital for acute right upper quadrant pain with low grade fever workup reveals acute colostitis laparoscopic colostomy is recommended turns out she has no living will no power of attorney that's doesn't surprise anybody probably married and has three children code status has never been previously addressed no surprise by default of course her code status is full code so should her code status be addressed in this setting and if so how should it be addressed and should advance directives be addressed and I'll come back and try to answer those questions in a minute case two is the middle category a 70-year-old man admitted to his local hospital for a two-day history of cough and fever of 103 degrees has a past medical history hypertension early COPD previous stroke with left mild hemiparesis and intermittent dysphagia he now has aspiration pneumonia and his respiratory status is getting tenuous so he also has no living well or power of attorney for health care he's widowed with four children he lives with his girlfriend that's a red flag for most of us in this group that is a little unclear who is a surrogate would be and he has no power of attorney but he also has no code status never been addressed code status is full code by default so the admitting physician should his code status be addressed and if so how should it be addressed and should advance directives be addressed and I hope everybody would answer that question yes given the complexity of his social relationships so case three so a 67-year-old woman is admitted to a local hospital for cough and fever found to have acute renal failure and is delirious turns out she has stage four lung cancer COPD CHF and chronic mild renal failure she did not tolerate chemotherapy which was attempted for a lung cancer subsequently she's been living in an extended care facility for three months she's an anorexia failure to thrive and progressive weight loss over those three months and now has been bedbound for the past two weeks she is diagnosed with post obstructive pneumonia she appears to be on the verge of respiratory failure so surprisingly she has no living well or power of attorney or unsurprisingly depending on your perspective she's widowed has one daughter who lives in town so at least we have an identified surrogate presumably code status again perhaps surprisingly perhaps not in the ECF was full code she nobody had gotten around to addressing that or else it had not been changed for one reason or another so should her code status be addressed if so how and should she or can she have advanced directives at this point no so this is what we as I go back a second sorry so if you recall these were the three categories we were talking about so we have one case in each of these three categories I'm going to go through them one at a time fairly quickly over as to why they're how they should be treated differently so it turns out if you have a basically healthy person the expected outcome in the hospital setting probably is about 20% survival to discharge if you have a cardiac arrest we all know out of hospitals different but there's one place out of hospital where the cardiac arrest outcomes are even better than the hospitals anybody know where that is the casino turns out casinos and there's actually a nice paper that shows about a 40% outcome of witness resuscitator cardiac arrest 40% recovery in a casino because people are basically healthy they get a shock to their system they arrest they're prepared for it they don't want dead people leaving their casino so that's the best place to have an arrest if you're wondering so but let's just say we have a healthy person this young woman comes in getting a procedure so I think many people would say the DNR discussion is really unnecessary because that if this was why we developed resuscitation was for people like this now some people would say yes you should have a discussion and maybe you should but I think we would all be a little surprised and disconcerted if the person wanted not to be resuscitated and I think that would make me concerned and make many people concerned that there's something else going on that we should investigate now on the other hand advanced care planning would be very appropriate because something bad could happen she could have a bad outcome she could have a neurological injury and so knowing what her preference is would be and who would be her decision maker would be very very helpful in the rationale as I sort of already said is that resuscitation is highly likely to improve survival in an otherwise healthy patient so it's highly indicated death would be a tragedy in this person because it's completely unexpected and there's no reason this woman should die except for some horrible tragedy so again the follow-up is then to provide advanced care planning and to prepare the person for possible future outcome bad outcomes now oops I'm going the wrong way again all right so number two this is the middle category and this is what we deal with 90% of the time in the hospital I think where we discuss code status so this is a person as the member the middle person who has COPD has had a stroke now has some pneumonia aspiration ammonia this person it's a very you know there's a realistic chance this person will die in the hospital many people would say it wouldn't be a horrible tragedy certainly not as much of a tragedy as the first person and in this this is precisely where DNR discussions are essential because really in this case you need to find out the person's values their preferences what constitutes quality of life it's you know all of the things that we usually do and having these DNR discussions it's really a matter of the patient's preferences based on a good understanding of the medical situation the likely outcomes etc and again outcomes are less good statistically than in the healthy person so and the follow-up would be that you would want to reevaluate this periodically because a person who's getting sicker might want to be full code initially and then change their mind or if they're getting better they might reverse their decision but it's also a situation where again you'd want to make sure you dealt with the advanced directives now this is the group where I think I hope I have something little different to say than what most people have said in the past so zero percent survival to discharge if you have a person who is imminently dying and I think this is the key if you go to the rationale this is the key point I want to make that a cardiac arrest in this situation is the mechanism of death not the cause of death and we don't treat mechanisms now I'm going to expand on that a little bit so if I'm standing here and my heart stops as far as I know I'm healthy feel free to try to resuscitate me because but for my cardiac arrest I'm not dying but if I have advanced cancer multiple other medical problems and I'm declining I'm dying from all of those combination of problems and eventually my heart stops that's the final event that's the mechanism by which I die it's not the cause of my death and treating mechanisms doesn't really make sense and if in fact the person is imminently dying their death is not preventable they are even if they survive the arrest they're not going to survive to leave the hospital or long beyond that now you could argue there's always a degree of irreducible uncertainty and I won't debate that but I think within reasonable medical uncertainty we can identify people who are mentally dying now so again in this case you could make an argument that this is a place where we would impose DNR status on people and people have made that assertion I don't think that's really necessary I think it's better to use this explanation this information to help people understand and you'll see my point in a minute but the follow-up here too I just want to emphasize so the follow-up here is that the patient is dying so we need to invoke palliative and supportive care we need to address anticipatory grief of physical emotional practical and spiritual aspects of dying and bereavement care so we really need to change our paradigm and obviously as a partner care physician people you know we we want to focus on all of these other aspects and help make the death less traumatic less painful for both the patient and the family and those who care for the patient so the key point again is that in this third group the recommendation for DNR unlike the first the third middle group it's not a value-based recommendation it's a medically based recommendation I think that's where we've been struggling all of these years is that we shouldn't impose our values on others but and we've I don't think we've had a good paradigm for saying this is where it's a medical decision but I think this is the the key criteria that when we're dealing with the mechanism of death there's no point in trying to treat that the underlying causes are not affected by treating the mechanism so in this setting I believe the appropriate thing to do is to actually recommend DNR status to be very clear that the patient is dying emphasize that the cardiac arrest is the mechanism and not the cause of death to say things like a temporary suscitation and if there's resistance obviously listen understand the source of the resistance often there's an emotional distress that is underlying the resistance as it turns out most people don't want to die you know even if they're old and sick and frail or young and sick and frail and they need help processing and preparing psychologically but I've never met a person who was dying who succeeded in not dying because they didn't want to so I don't think you can take that as a as a reason to not go there so emphasizing the outcomes in the negative and again if you're there's resistance emphasizing the outcomes negative effects and the benefits so two quick more slides so an example of the script unfortunately you disease is terminal and will soon cause your death when that happens your heart and breathing will stop any attempt to resuscitate you will fail I recommend that at that time we focus on assuring your comfort and allow you to die peacefully and naturally does that make sense to you so you say that to the patient or the family depending on the situation another example of critical care and this is we see obviously most of us have seen this currently we are doing everything we can to support your loved ones vital function vital functions if despite these efforts her heart stops any attempt to resuscitate or worth will fail I recommend that if that happens we focus on assuring her comfort and allow her to die as peacefully naturally as possible does that make sense to you again you're making a recommendation it's medically based and you're asking for their assent so I won't reiterate this because we're out of time I think I've made my point thank you hello Charles Ray I'm a palliative care physician here at the University of Chicago I have a few question about where in someone's medical training would you start this and how you know in terms of the appropriateness of this conversation I when it comes to your typical intake of code status I've heard everything from residents on the spectrum of well if your heart were to start you want us to start it back up again to the other end of the spectrum where it's like well it's gonna crack your ribs and puncture lungs like really painting dire consequences and you know neither are really kind of an ideal way to frame this discussion so do you have any thoughts in terms of how to further education on this topic and how to have these conversations well I think the easiest way to think about imminent death is to start where we're absolutely certain it's imminent and work backwards because if we try to go the other way it's very very hard of course in the real world we have to start at the other end and go forward and I think this is an example of where experience and observation help there's one of the fast facts David Wiseman talks about the signs of imminent death and there are many times I walk into them and see the patient and say they're dying and everybody around me is like what and so you know it's it's part of it's just having a recognition of that but I do think we can see people and as you saw in that study they recognize these people as people in whom they anticipated the heart would be stopping and yet they resuscitated them I don't know what kinds of conversations they had the other point I would make is obviously this doesn't always work but my experience is that it works quite a bit more often than not and it relieves a lot of distress from the families and patients because they don't feel like they're making a decision to give up on somebody they're just acknowledging the situation and the reality so I think there's actually I didn't have time to go into this there are criteria for imminent death so one of the bed bound for two weeks decreasing mental status decreasing urine output things like that obviously modeling cold extremities etc so there are criteria you can use and obviously context advanced cancer advanced heart disease etc seeing these signs in that kind of a patient you're more likely to be confident there's imminent death I found that distinction between mechanism of death and cause of death to be very illuminated and and you used it to indicate that when the physicians were recommending against resuscitation I think you made that point it was not based on a value judgment but on a medical this decision one for which there was hard data and hard evidence yeah thanks so much