Anissa Carver, Jenny Goff, Alyson Claywell, Denny Fugate, Kevin Poe
Diagnosis of Death: In order to ensure appropriate patient care and to decrease the chances of a staff physician becoming involved in the legal consequences of a patient's death, the University of Kentucky Hospital requires that each physician follow established guidelines in determining (cerebral) death in the presence of heartbeat and relatively normal blood pressure.
Care of terminally ill patients: When a medical faculty member recognizes an impending death, the faculty member will place a note to that effect in the patient's chart. The note should be clear and concise and should specifically describe the patient's terminal illness, the anticipated prognosis, the therapeutic plan for disease treatment and patient comfort, and orders for the patient prior to death. In addition, the note should provide guidance to the nursing, hospital, and resident staff for carrying out the treatment plan. It should include the patient's or family's expressed wishes concerning medical management of terminal care prior to or during hospitalization. A signed informed consent is strongly recommended if the terminal care plan includes orders not to resuscitate. It should also include names and relationships of family participants and hospital or medical staff involved. Do not resuscitate (DNR) orders are defined as do not call the arrest team and do not start basic cardiac life support (CPR). These orders cannot be verbal orders but must be recorded in the patient's medical record to be valid. The order can be written only by the patient's attending physician. The orders should be written only after discussion with the patient if competent or with the patient's family, legal guardian, or other appropriate party if patient is incompetent or a minor. DNR orders do not imply that any other treatment will be discontinued. When a DNR patient is taken to the operating room for a surgical procedure, this step voids all standing orders, including the DNR. Following an operation, the DNR order must be re-evaluated to determine reinstitution. There are other types of orders also. Selective treatment limitations (STL) define certain limitations that address potentially life-threatening conditions and may or may not include DNR orders. Palliative care only (PCO) orders allow for only therapeutic measures that are necessary to alleviate symptoms. These orders also may or may not include DNR orders. All of these orders are specific for the condition defined and do not override the judgement and treatment decisions of physicians in time of acute emergencies. If the treatment plan includes an order to withhold resuscitation or other major therapeutic measures, the attending should notify the Risk Manager or Associate Dean for Clinical Affairs. Before any order to withhold resuscitation can be issued, the patient or legal representative must sign an informed consent.
The goal to providing care for the terminally ill should be to provide patients with a peaceful and dignified death, without pain and with as little anguish and anxiety as possible. However, dying in an acute care hospital is associate with depersonalization, regimentation and perceptions of unmet need on the part of the patient and family, not to mention the patient's loss of autonomy. More than 50% of Americans die in hospitals, and many of these deaths are in physical and mental anguish. A study done by Dartmouth Medical Researchers found that the type of care a patient receives in their dying days varies in different parts of the country. A different study showed many patients endure prolonged, painful deaths in which physicians often ignore their "living wills" and other requests to withhold "heroic" treatments. Much of the problem is thought to be due to physicians' lack of good communication skills, do not explain situations well and are trained to see death as failure. SUPPORT was a program designed to change terminally ill care. The results of this study can be found in Box 5-3 on page 103 of our book. Two changes must occur in order to improve terminally ill care. The first is a change in our cultural attitudes and accept death as a natural phenomenon. And the second, our health care institutions must commit more resources to improving end-of-life care.
Concerning technological life support equipment, mainly ventilatory support and intervention intubation are the two key players. Three forms of ventilatory support include controlled mechanical ventilation, intermittent mandatory ventilation and pressure support ventilation. The latter is the newest and most favorable form involving an increased interaction of breathing mechanisms between the patient and the machine. Three forms of intervention intubation also exist including endotracheal, nasogastric, and gastric. The main purpose of intubation is to deliver food, liquids, or gases into the lungs or stomach via passage of a tube into that body space. Two risks have been found with the use of this equipment: brain damage and perforation. Perforation results when an intubation tube accidentally punches a hole into a body surface lining. Because of these risks, many people prefer to avoid these procedures, but most people accept the risks in hopes of surviving. Accordingly, as human nature behaves, many patients may change their minds on this topic so periodical reviews of a terminally ill patient's wishes should be conducted. A "life support dilemma" has emerged because although only a handful of practitioners condone life support use for the terminally ill, the procedures are performed and used quite regularly. Currently, a balance is missing between the patient's dignity, the family's desires, and the appropriate use of medical technology at the end of life.
Of all the patients that spend time in a hospital, we know in advance that a portion of them will inevitably die due to a terminal illness. In these patients, there are two main goals of pharmacotherapy, both of which are aimed at providing comfort to the patient. Many terminal illnesses like cancer are associated with extremely severe pain. The gold standard of pain relief in cancer patients is the Patient Controlled Administration (PCA) of morphine. The PCA device eliminates the physician guessing game as to how much pain the patient is experiencing, allows the patient to "self-dose" until comfort is achieved, and may reduce the risk of undesirable side effects such as hallucinations and thought impairment. However, there is a limit as to how much medicine the patient can receive in a given period of time. The other goal to pharmacotherapy is anxiety management. Awareness of imminent death naturally may result in anxiety and depression. Several agents are used to manage these symptoms during the final days. The most prominent being Valium® and Xanax®.
1. The University of Kentucky Hospital has established guidelines that define the boundaries of death. All physicians are required to follow these guidelines to ensure appropriate care is given and legal consequences are avoided.
2. These policies set forth by the University of Kentucky Hospital are established to protect the legal, ethical, and educational issues surrounding terminally ill patients; these policies include determination of death and Do Not Resuscitate (DNR) orders.
3. The actions taken by health care professionals do not always follow established hospital policies. Furthermore, these actions are also not always in the best interest of the patient.
4. Ventilation support and intervention intubation are two of the many forms of life-sustaining technologies that are used on a regular basis; however, many patients and doctors prefer not to utilize these measures.
5. The two main goals of therapy for the final days of a terminally ill patient are pain management and emotional management.
I realize that I took for granted the seriousness of death in relation to health care. It seems from an individual's bias viewpoint decisions are easy and have few repercussions. The world slapped me in the face when it took me five days to receive a copy of the hospital's policy on the diagnosis of death and the care of terminally ill patients. I was moved from Patient Assistance to Hospital Risk Management to the Associate Dean of Hospital Affairs. I was then asked a series of questions such as for what purpose am I using the material and to how many persons would be reviewing the material. After I told them that I was using it for a report they insisted on knowing my major and if I worked at the institution. I was also informed that it was not legal for me to make photocopies of hospital policy for public distribution then confirmation was made on me being in pharmacy school and a hospital employee and I was given the information.
DIAGNOSIS OF DEATH:
In order to ensure appropriate patient care and to decrease the chances of a staff physician becoming involved in the legal consequences of a patient's death, the University of Kentucky Hospital requires that each physician follow established guidelines in determining death.
***SEE BELOW FOR DEATH CRITERIA***
CARE OF TERMINALLY ILL PATIENTS:
When a Medical faculty member recognizes an impending death, the faculty member will place a note to that effect in the patient's chart. The not should be clear and concise and should specifically describe the patient's terminal illness, the anticipated prognosis, the therapeutic plan for disease treatment and patient comfort, and orders for the patient prior to death. In addition, the note should provide guidance to the Nursing, Hospital, and Resident staff for carrying out the treatment plan. The note also should document communications with the patient and/or family.
The note on family communication should include:
1. The patient's, if possible, and/or family's expressed wishes
concerning medical management of terminal care prior to or during hospitalization. A signed informed consent is strongly recommended if the terminal care plan includes orders not to resuscitate. If a signed informed consent is not obtained, the medical and/or nursing staff members who witnessed the discussion with and concurrence of the family must document such in the medical chart.
2. Names and relationships of family participants.
3. Names and relationships of hospital and medical staff involved.
Do Not Resuscitate orders can have four major formats. These orders to carry out the treatment plan should be carried out according to the following principles.
***SEE BELOW FOR DNR ORDERS***
DNR, STL, PCO, STW orders are specific for the condition defined
and does not override the judgment and treatment decisions of physicians
in time of acute emergencies or conditions. If the treatment plan includes
an order to withhold resuscitation or other major therapeutic measures
such as volume respirators, dialysis, or vasopressors, the attending should
notify the Risk Manager or Associate Dean for Clinical Affairs. Before
any order to withhold resuscitation can be issued, the patient or legal
representative must sign an informed consent or the family's concurrence
with the defined plan must be witnessed and documented in the medical chart
by a Hospital or Medical staff member. If communication problems arise
between staff and patient/family, the physician or nurse should contact
the Risk Manager. If a ethical dilemma to any of the principals, including
family, the physician should contact the Associate Dean for Clinical Affairs.
Currently acceptable criteria for determination of cerebral death in the presence of heartbeat and relatively normal blood pressure, whether or not artificial means are used to maintain the circulation of oxygenated blood, shall include:
1.) Absence of hypothermia(32.2 C), neuromuscular blockade, shock, and significant levels of sedatives and central nervous system depressants in patient's serum; severe metabolic disorders.
2.) Cerebral unconsciousness and motor unresponsiveness to stimuli which normally causes intense pain.
3.) Absence of spontaneous movements for an observation period of at least on hour.
4.) Absence of reflexes which involve cranial nerves. The pupils must be fixed mid point in diameter and nonreactive to sharp changes in the intensity of light. No ocular responses or eye movements to head turning or irrigation of ear with ice water.
5.) Absence of corneal reflexes.
6.) No gag, cough, or retching reflex in response to bronchial stimulation with suction catheter.
7.) No respiratory movements occur when the patient is disconnected from the mechanical ventilator. Adequate testing for apnea is very important. An accepted method is ventilation with pure oxygen for a 10 minute period before withdrawl of the ventilator followed by passive flow of oxygen. A 10 minute period of apnea is sufficient to attain hypercarbia which adequately stimulates a respiratory effort. Testing of arterial blood gases can be used to confirm this level. Any spontaneous breathing efforts indicates that part of the brainstem is functioning and that the patient is not brain dead.
When the preceding reflexes cannot be adequately assessed and documented, or in children under the age of five, an additional confirmatory test is recommended.
1.) An EEG, obtained under the supervision of a recognized electroencephalographer, demonstrating isoelectric activity, provided that criteria in previous #1 is not present.
2.) Angiography revealing absence of cerebral circulation.
3.) Short latency auditory or somatosensory evoked potentials demonstrating absent brainstem and cortical activation.
In the absence of confirmatory tests, the seven conditions described earlier must persist unchanged for at least 12 hours.
In the presence of confirmatory tests, a six hour period is required.
In anoxia brain death, a 24 hour observation period or demonstrated EEG silence and 12 hours of observation is required.
In cases of children under the age of one year, 72 hours of observation and an EEG demonstrating isoelectric activity is required.
In cases of children aged one through five, 24 hours of observation and isoelectric activity on EEG is required.
In cases of brain injury where there is such gross anatomical damage visible on physical examination or craniotomy as to indicate that the brain is irreparably damaged, extruded, divided, or destroyed, the period of observation for the persistence of the conditions described earlier may be reduced to one hour.
DNR orders are defined as do not call the arrest team and do not start basic cardiac life support (i.e. CPR).
DNR orders cannot be verbal orders but must be recorded in the patient's medical record to be valid. The order can be written only by the patient's attending physician. The orders should be written only after discussion with the patient if competent or with the patient's family, legal guardian, or other appropriate party if patient is incompetent or a minor.
DNR orders does not imply that any other treatment will be discontinued.
When DNR patient is taken to the operating room for a surgical procedure, this step voids all standing orders, including the DNR. Following an operation, the DNR order must be re-evaluated to determine reinstitution.
SELECTIVE TREATMENT LIMITATIONS (DNR/STL) OR (STL):
STL will generally call for DNR as well as defined limitations. Selective treatment limitations with or without DNR address potentially life-threatening conditions where treatment may be limited in some or all of the following ways:
-No vasopressors/ inotropic agents
-No mechanical ventilation
-No antiarrhythmic drugs
-No transfer to an ICU
-No blood/blood products
-No electrolyte or acid-base corrective measures
Treatment limitations may also include orders to withdraw or discontinue these or other interventions.
PALLIATIVE CARE ONLY (DNR/PCO):
DNR/PCO order accompanied by a do not resuscitation orders means
there should be no resuscitation, no new treatment, and cessation of all
diagnosis and therapeutic measures except those which are necessary to
alleviate symptoms. No measurement of vial signs, diagnostic tests, or
monitoring should be undertaken. Drugs and ventilator support should be
provided only with specific written orders for the purposes of relieving
DNR PLUS SPECIFIED TREATMENT WITHDRAWAL (DNR/STW):
Medical treatment not ordered or not renewed is not to be given. For terminally ill patients treatments are not necessary unless specifically ordered as necessary to relieve unnecessary pain.
Even though no new treatment is ordered, the means to provide that
treatment may remanin in place, leaving the nursing staff with an unresolved
dilemma. Therefore, when the physical means for providing that treatment
remain in place, the physician should personally remove or disconnect the
The presentation flowed smoothly but possibly was "too informative" concerning hospital policy. Most everyone said they thought we did a good job. The main criticisms were that the material was dry. This we did not see as being our fault and being difficult to spice up a depressive topic. Overall, attentiveness of the class seemed to be maintained.
The presentation was divided into five parts amongst
the group members. Everyone did their own research on their topic and it
was all brought together and decided on an order of presentation. Alyson
did research on Hospice which was left out due to a future presentation.
However, she probably had the hardest job of all with the introduction
and conclusion. Jenny's research involved internet searches for information
and possible visual aids as well as reviewing journal articles from accredited
medical journals. Anissa's research came directly from internet searches
and articles. Denny explained the chains he went through in order to obtain
hospital policy in class. And Kevin's research involved referencing previous
pharmacy class notes on pain management and discussions with professors.