Fluctuating Code Status: Strategies to Minimize End-of-Life Conflict in the Neurocritical Care Setting

2021 ◽  
pp. 104990912110178
Author(s):  
Kelly A. Rath ◽  
Kristi L. Tucker ◽  
Ariane Lewis
Keyword(s):  
Decision Making ◽  
End Of Life ◽  
Care Setting ◽  
Ethical Issues ◽  
Severe Illness ◽  
Healthcare Team ◽  
Do Not Resuscitate ◽  
Comfort Care ◽  
Goals Of Care ◽  
Code Status

Background: There are multiple factors that may cause end-of-life conflict in the critical care setting. These include severe illness, family distress, lack of awareness about a patient’s wishes, prognostic uncertainty, and the participation of multiple providers in goals-of-care discussions. Methods: Case report and discussion of the associated ethical issues. Results: We present a case of a patient with a pontine stroke, in which the family struggled with decision-making about goals-of-care, leading to fluctuation in code status from Full Code to Do Not Resuscitate-Comfort Care, then back to Full Code, and finally to Do Not Resuscitate-Do Not Intubate. We discuss factors that contributed to this situation and methods to avoid conflict. Additionally, we review the effects of discord at the end-of-life on patients, families, and the healthcare team. Conclusion: It is imperative that healthcare teams proactively collaborate with families to minimize end-of-life conflict by emphasizing decision-making that prioritizes the best interest and autonomy of the patient.

scholarly journals L’utilisation des échelles de niveaux d’interventions médicales en centre hospitalier

2016 ◽  
Vol 35 (1) ◽  
pp. 70-78
Author(s):  
Marjolaine Frenette ◽  
Jocelyne Saint-Arnaud
Keyword(s):  
Decision Making ◽  
End Of Life ◽  
End Of Life Care ◽  
Treatment Options ◽  
Medical Intervention ◽  
Treatment Withdrawal ◽  
Decision Making Process ◽  
Do Not Resuscitate ◽  
Code Status ◽  
Levels Of Care

ABSTRACTDifferent care settings in Quebec use levels of medical intervention forms, also called levels of care (LOC), to determine the code status of patients and to improve end-of-life care planning. It is not currently possible to know whether the levels of care in hospitals benefit patients and staff in facilitating the decision making process of treatment options and resuscitation measures. No study, to the best of the authors’ knowledge, has been published about LOC, particularly in Quebec and Canada. This literature review was undertaken on levels of care in order to clarify this topic. Relevant articles are discussed under different themes that are pertinent to LOC. The themes addressed in this article include care at the end of life, do-not-resuscitate orders, treatment withdrawal, and decision making at end of life.

The pyramid of treatment levels: A tool to convey goal-based treatment options.

2018 ◽  
Vol 36 (34_suppl) ◽  
pp. 147-147
Author(s):  
Heather Leeper ◽  
Andrew Kamell
Keyword(s):  
Decision Making ◽  
Medical Care ◽  
End Of Life ◽  
Symptom Management ◽  
End Of Life Care ◽  
Life Care ◽  
Care Providers ◽  
Goals Of Care ◽  
Code Status ◽  
Wide Range

147 Background: 60% of Americans die in acute care hospitals and under 40% of advanced cancer patients have end-of-life care discussions with their health care providers. Didactic methods and tools to teach about symptom management, navigation of treatment decisions, code status, and end-of-life care decisions within an inpatient setting are a necessity to meet this high demand. Methods: A model of medical care systematically dividing clinical management decisions into escalating levels of medical care relative to illness severity, treatment goals, and code status was created. The model is illustrated as a pyramid with a base of symptom management as the initial level of medical care. The second level represents disease-focused medical care including antibiotics, disease-modifying drugs, and chemotherapy administration. Hospitalization with increasingly complex and invasive interventions represents the third level followed by critical illness care including ICU admission and vasopressors as the fourth level. Intubation comprises the fifth level and CPR forms the top of the pyramid. Results: This model has been used extensively at our institution in educating medical students, residents, fellows, and faculty. All groups reported it was helpful in understanding POLST forms, code status, and collaboratively developing appropriate goal-based care plans with their patients. Symptom management remaining as a non-negotiable foundation of care emphasizes its importance. This depiction of medical care may facilitate goals of care and code status discussions and is particularly helpful for determining appropriate care goals or options when considering de-escalation of medical therapies. Used implicitly or explicitly in patient and family discussions, it has facilitated decision-making and discerning the appropriateness of the overall treatment plan relative to patient goals of care. Conclusions: This model of care with its companion pyramid accommodate a wide range of clinical scenarios, is an effective, high yield didactic device for patients, families, and healthcare providers alike, and has applications as supportive tool to optimize goal-based clinical decision making in the context of serious illness.

scholarly journals Use of Video to Facilitate End-of-Life Discussions With Patients With Cancer: A Randomized Controlled Trial

2010 ◽  
Vol 28 (2) ◽  
pp. 305-310 ◽  
Author(s):  
Areej El-Jawahri ◽  
Lisa M. Podgurski ◽  
April F. Eichler ◽  
Scott R. Plotkin ◽  
Jennifer S. Temel ◽  
...  
Keyword(s):  
Decision Making ◽  
End Of Life ◽  
Controlled Trial ◽  
Verbal Description ◽  
Comfort Care ◽  
Goals Of Care ◽  
Patients With Cancer ◽  
Basic Care ◽  
End Of Life Decision ◽  
Life Decision

Purpose To determine whether the use of a goals-of-care video to supplement a verbal description can improve end-of-life decision making for patients with cancer. Methods Fifty participants with malignant glioma were randomly assigned to either a verbal narrative of goals-of-care options at the end of life (control), or a video after the same verbal narrative (intervention) in this randomized controlled trial. The video depicts three levels of medical care: life-prolonging care (cardiopulmonary resuscitation [CPR], ventilation), basic care (hospitalization, no CPR), and comfort care (symptom relief). The primary study outcome was participants' preferences for end-of-life care. The secondary outcome was participants' uncertainty regarding decision making (score range, 3 to 15; higher score indicating less uncertainty). Participants' comfort level with the video was also measured. Results Fifty participants were randomly assigned to either the verbal narrative (n = 27) or video (n = 23). After the verbal description, 25.9% of participants preferred life-prolonging care, 51.9% basic care, and 22.2% comfort care. In the video arm, no participants preferred life-prolonging care, 4.4% preferred basic care, 91.3% preferred comfort care, and 4.4% were uncertain (P < .0001). The mean uncertainty score was higher in the video group than in the verbal group (13.7 v 11.5, respectively; P < .002). In the intervention arm, 82.6% of participants reported being very comfortable watching the video. Conclusion Compared with participants who only heard a verbal description, participants who viewed a goals-of-care video were more likely to prefer comfort care and avoid CPR, and were more certain of their end-of-life decision making. Participants reported feeling comfortable watching the video.

Specific Ethical Issues at the End of Life (DRAFT)

2018 ◽  
Author(s):  
Robert C. Macauley
Keyword(s):  
Decision Making ◽  
End Of Life ◽  
Advance Care Planning ◽  
Ethical Issues ◽  
Care Planning ◽  
High Burden ◽  
Code Status ◽  
Decision Making Capacity ◽  
Advance Care

A specific application of advance care planning has to do with determining the “code status” of a patient. Many of the terms used to document this status are misunderstood or carry unfortunate connotations, such as “DNR.” It is more appropriate to refer to a “Do Not Attempt Resuscitation” (DNAR), to emphasize the uncertainty as to whether attempted resuscitation will be successful. Code status is especially relevant to patients who “want everything,” which may include high-burden and low-benefit procedures. Time-limited trials and Do Not Escalate Treatment orders may be considered in those situations. There may also be situations when a patient’s refusal should be overridden, when the patient’s decision-making capacity is compromised.

Decision making on clinical care choices including end-of-life decision making for older adults in an acute care setting

2020 ◽  
Vol 70 (suppl 1) ◽  
pp. bjgp20X711725
Author(s):  
Sinead O’Reilly
Keyword(s):  
Decision Making ◽  
Older People ◽  
Medical Care ◽  
End Of Life ◽  
Older Patients ◽  
Care Setting ◽  
Clinical Care ◽  
Care Plan ◽  
Do Not Resuscitate ◽  
Health And Social Care

BackgroundThe Scottish Government’s vision for older people is that ‘Older people are valued as an asset; their voices are heard and they are supported to enjoy full and positive lives.’ In the health and social care setting in Scotland it is increasingly recognised that there is a need for careful planning of care for older patients with complex comorbidities, and that this should involve the patient where possible via a process of shared decision making (SDM).AimTo establish what future planning for healthcare decision making and end-of-life care was undertaken in the care of the older patients in a secondary care facility, and how much they participate in this process.MethodAn audit was conducted across four wards in the care of the older patient setting in a hospital for older patients in Scotland. Over a 2-week period, all patients’ charts (n = 82) were reviewed, and evidence was examined on whether the following documents were in place: a do not resuscitate order; an escalation of medical care plan; and an assessment of capacity/incapacity.ResultsThe majority of patients (55%) had a resuscitation plan in place. An Incapacity Statement was also in place for the majority of patients who required it (90%). The escalation of medical care plan was only completed for a minority of patients, mainly those on the palliative care ward.ConclusionPlans for decision making around resuscitation were reasonably well developed. However, planning for other, more complex, future medical care needs was less well defined or explored with older patients.

End-of-life decision making in critical illness: Perspectives of Asian parents

2021 ◽  
pp. 1-10
Author(s):  
Kristy Xinghan Fu ◽  
Yee Keow Chiong ◽  
Nicola Ngiam
Keyword(s):  
Decision Making ◽  
End Of Life ◽  
Tertiary Care ◽  
Asian Population ◽  
Emergency Department Visits ◽  
Case Vignette ◽  
Healthcare Team ◽  
Care Hospital ◽  
Case Vignettes ◽  
End Of Life Decision

Abstract Objective To explore parents’ perspectives regarding end-of-life (EOL) decisions, factors and possible barriers that influence the EOL decision making process, and to understand parental preferences for communication about EOL care in an Asian population. Method A prospective questionnaire cohort study conducted in a university-based tertiary care hospital. 30 parents of children who had been admitted to general pediatric wards for acute ailments and/or were being followed up in general pediatric outpatient clinics after inpatient admissions or emergency department visits completed 30 interviewer-administered questionnaires. With the first 10 completed questionnaires, we sought feedback on the design of the four case vignettes and related questions. Responses to specific questions related to each case vignette were rated on a Likert scale. Results The majority of parents were able to comprehend and identify with the issues in the case vignettes, which allowed them to respond appropriately. Parents tended to avoid active withdrawal or withholding of life-sustaining treatment. The top three priorities for parents making EOL decisions for their children were: the chance of improvement, the presence of pain or discomfort, and information provided by healthcare staff. Parents reported that they would prefer to know immediately if their child is at risk of dying; they also preferred to get as much information as possible from the healthcare team and thought that meeting with the healthcare team before making EOL decisions was pivotal. Significance of results Parents place highest priorities on their child's likelihood of improvement, perception of their child's pain, and information provided by healthcare professionals in making EOL decisions.

scholarly journals PERSPECTIVES ON SETTING GOALS OF CARE AMONG HOSPICE PATIENTS WITH HEART FAILURE, THEIR FAMILIES, AND HEALTHCARE TEAM

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S791-S792
Author(s):  
Dawon Baik ◽  
David Russell ◽  
Lizeyka Jordan ◽  
Frances Dooley ◽  
Ruth Masterson Creber
Keyword(s):  
Heart Failure ◽  
End Of Life ◽  
Family Caregivers ◽  
Qualitative Interviews ◽  
Active Listening ◽  
Healthcare Team ◽  
Goals Of Care ◽  
For Profit ◽  
Care Plans ◽  
Life Trajectory

Abstract Older adults with heart failure (HF) face many end-of-life care issues. Shared decision making (SDM) in hospice is an important process that allows HF patients and their family caregivers to discuss their preferences on goals of care (GOC) with their healthcare team. Yet, little research has explored how the values and preferences of HF patients and their family are integrated into their care plans through SDM process. This presentation examines facilitators and barriers to setting GOC among hospice HF patients. Qualitative interviews were conducted with HF patients/family caregivers (n=7) and providers (n=32) at a large not-for-profit hospice agency. Several facilitators emerged: building trust, active listening, helping patients and family caregivers understand hospice and prognosis. Barriers included acceptance, family conflict, language discordance between patients and providers and lack of communication about care transition. Findings confirmed the need for individually-tailored goal-setting approaches to navigating the end-of-life trajectory among HF patients.

scholarly journals The bioethics of end-of-life care in Internal Medicine: decision making and setting of care

2013 ◽  
pp. 133-138
Author(s):  
Giancarlo Traisci
Keyword(s):  
Internal Medicine ◽  
Decision Making ◽  
End Of Life ◽  
End Of Life Care ◽  
Ethical Issues ◽  
Present Report ◽  
Clinical Care ◽  
Terminal Phase ◽  
Life Care ◽  
Physician Patient Relationship

Introduction In the field of Internal Medicine, the management of the terminal phase of an illness raises important issues involving clinical care, with particular reference to the physician-patient relationship. The present report describes the professional code of conduct relative to the assessments and decision making involved in end-of-life care. Materials and methods The article summarizes and discusses Italian common deontological low and the current positions of national and international experts in the field of end-of-life care. Results The ethical issues regarding euthanasia, withdrawal/withholding of health care, and medical treatment that uselessly prolongs the life of a terminal patient are defined and analyzed in conjunction with the outcomes suggested by the palliative medicine. Discussion Physicians caring for patients at the end of their lives must give consideration to bioethical approach.

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