Unilateral DNR? Gina Piscitello, Erin DeMartino, Will Parker

Eric 00:16

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:19

This is Alex Smith.

Eric 00:20

And, Alex, we’re going to be talking about unilateral DNRs. We did a podcast on slow codes not too long ago. We’ll have links to that on our show. Notes. One of our guests was on that podcast. Alex, who are our whole guests today?

Alex 00:34

We’re delighted to welcome back from that podcast Gina Piscatello, who is a palliative care doc, an ethicist, and a researcher at the University of Pittsburgh. Gina, welcome back to the GeriPal Podcast.

Gina 00:46

Thanks for having me.

Alex 00:48

And we’re delighted to welcome Erin DeMartino, a pulmonary critical care doc, ethicist, researcher at the Mayo Clinic in Rochester, Minnesota, where the current temperature is negative 5, negative 5. But it was negative 4, negative 24. This weekend, she’s saying, welcome to the GeriPal Podcast.

Eric 01:07

You’re going to go out with a T shirt today. It’s warmed up.

Erin 01:11

No, not that warm.

Alex 01:14

And we’re delighted to welcome Will Parker, who is an intensivist, ethicist, and researcher at the University of Chicago. Will, welcome to the GeriPal Podcast.

Will 01:23

Happy to be here.

Eric 01:25

So we got a lot of talk about unilateral DNRs and something I’ve never heard of before, unilateral DNR orders. But before we jump into that subject, we always have a song request. Gina, do you have the song?

Gina 01:38

I do. It is Heartbreaker by Pat Benatar.

Eric 01:41

Why did you choose Heartbreaker?

Gina 01:43

The reason is that oftentimes when unilateral DNRs are done, it’s because doctors and nurses, they don’t want to break the patient’s heart.

Erin 01:49

So therefore, Heartbreaker.

Alex 01:52

That’s a good one. All right. This is a fun one. Good energy. Here we go.

Alex 02:01

(singing)

Alex 02:52

That was a fun one. Thank you, Gina.

Eric 02:54

Okay, Gina, I’m going to start off with you. We’re talking about unilateral DNRs. Can you tell me what a unilateral DNR is?

Gina 03:02

So these are DNRS that the doctor decides to not perform CPR on the patient. So it does not depend on the patient or surrogate consent to the DNR order. It is physician generated. Now, the patient and surrogate, they might consent to it, but it’s not necessary for the unilateral DNR order to be pursued.

Eric 03:21

So it’s not during a code. A doctor decides not to do the code. It’s prior to the code, it’s, I’m going to put in a DNR order that the patient has not consented or the family has not consented. Is that right?

Gina 03:33

Yes. Ideally before. Yes.

Eric 03:35

Yeah.

Will 03:36

But yeah, Eric, you know, to jump in, your, your comment about during a code is an interesting one. Right. Because we end resuscitation after usually 20 or 30 minutes and say CPR is not going to be successful and we unilaterally decide to stop doing CPR at some point. That is an entirely clinician initiated decision. And now with advances in technology like VA ecmo, there ultimately is always a subjective judgment that a clinician is making about whether to provide CPR or other resuscitated measures. Whether you’ve attempted initially or not, there’s still a unilateral nature that’s unavoidable now.

Erin 04:18

Yeah. And how long you keep going? Do you do several rounds or do you do 15 rounds? And at what point you may consider extra corporeal support?

Eric 04:28

You know, I encourage all our listeners to watch the Rethinking Slow Codes podcast. We talk a lot about all this, but like in the healthcare system I work at, we can’t do unilateral DNRs at all. But so somebody has to be full code. But if they arrest, a physician does not have to. And a code team does not have to code somebody if they think it is non beneficial.

So at least in our healthcare system, they’re separating unilateral DNRs, which is, you know, before the code to during the code, from saying you don’t have to provide non beneficial care. You just, you still have to figure out is there anything reversible like did the trach fell off. But it, it does bring up this question about like definition of what we’re thinking about unaltery and r. Cause I don’t, I don’t think most people would think that applies during the arrest.

Erin 05:20

Right, right, you’re right about that. Yeah. And I also think that what you’re describing illustrates Some variation that we discovered even amongst ourselves as we were collaborating and writing about that. This, that each institution that we’re in handles these types of situations differently and may even label them differently.

Eric 05:41

Yeah, fascinating. Can I ask just quickly why each of you decided like, hey, this is a great thing that we should think about and write about. We got a palp care doctor and two intensivists. Erin, I’ll, I’ll start off with you. Like, what motivated you?

Erin 05:58

Well, I was motivated by working with two amazing colleagues who also think about this type of issue really frequently. I was particularly interested. I’ve done work on how policy variation may translate into different types of practice in different settings across the country. And so the opportunity to kind of measure that and try to quantify it, see what’s written in statutes about justifications for unilaterally withholding a life sustaining therapy, that was really what drove me to want to be a part of the project.

Eric 06:33

And have you personally done it?

Erin 06:36

So actually that’s an interesting question. At my institution, there isn’t an ability to enter a unilateral DNR order. And I don’t just mean labeling the order as unilateral. We don’t institutionally condone the practice of unilaterally withholding a life sustaining therapy. And so a patient who expresses, or patient or family who expresses opposition to a proposed withholding of a life sustaining therapy will receive CPR at our institution.

Eric 07:12

Does everybody get ecmo?

Will 07:15

No.

Eric 07:16

So there are some licensing therapies that we will. Okay, well, let’s, let’s hold on.

Erin 07:22

ECMO is not a default state where a CPR is.

Gina 07:25

Right.

Erin 07:26

ECMO is not a default state of, you know, anybody who doesn’t have a DNR order will receive CPR. And so that is the default state.

Eric 07:36

So it’s. Does the policy just apply to DNR or is it life sustaining treatments in general?

Erin 07:42

Dnr, dnr.

Eric 07:43

Okay, Will, what got you interested in this?

Will 07:47

Well, I think. Yeah, conversations about our practice patterns I think motivated us too. Erin and I are often in situations where we feel like CPR would be strictly futile in the sense that the probability of restoring ROSC when the patient arrests from refractory septic shock, let’s say, is essentially zero.

Eric 08:10

Yeah, we know.

Alex 08:11

Just some, some of our.

Will 08:12

Oh, sorry. Return of. Yeah, return of spontaneous circulation. So the patient’s heart stops. We can do chest compressions and give medications. And we’re trying to attempt to have the, the patient’s circulate heart restart and the circulation resume in such a way that the organs will be perfused and the. The state will be somewhat permanent. Right. May require life support, but that’s the goal of CPR. So sometimes, clinically, we can be quite, quite sure that if we do this CPR, we are not going to achieve that state because we’ve been taking care of the patient for days and we’ve sort of seen the trajectory downward.

And so often kind of walk in the room and say, you know, we’re not going to do CPR. Here’s why. And it’s not a question, it’s just a. It’s a statement of fact from our medical opinion. And often the family says, okay, and then the intern puts in a DNR order in the chart. But as I think Gina brought up at the beginning of the podcast, well, that was a unilateral decision that I made as an intensivist. The family assented to my decision. They didn’t say no, and they accepted it. And maybe if I had asked, do you still want us to do it anyway, despite what I’ve told you, they might have said no. That’s. That’s crazy.

You explain why, but we didn’t ask a question, so we didn’t really know. And so I think that was one of the central things we were trying to get at in our manuscript, is that we think that a lot of patients who are made do not resuscitate in critical care units actually might fall into this category of ascent, unilateral DNRs, which are a sort of silent practice that’s not documented in the electronic healthcare record.

Eric 10:01

Hmm. I wanna get back into this. Ascent versus the conflict. I think you wrote DNRs, but before we do, I just wanna ask Gina the same thing. Gina, it’s specifically about unilateral DNRs. Like we talked about slow code the last time you were on. Cause you’ve done some research on this. What motivated you to dive into this topic?

Gina 10:22

Yeah, I think as a resident, I didn’t believe, I didn’t know unilateral DNRs were a thing. And then you see them in practice, and it just like blew my mind because I always was taught in medical school. You know, you offer the options to patients, families, they decide. And then to see that that is not the case in practice, and then hearing from people, you know, across the country, how practice differs so, you know, dramatically. I think that’s been my.

My passion. Just been kind of like empirically assessing what is happening. Because I think, you know, these, these are really difficult decisions. These affect patients and families greatly, as well as the medical teams. I just think we should do this the best that we can. And in order to do it the best that we can, we need empirical data to, you know, identify what we’re doing.

Alex 11:01

Speaking of confusion across settings, Eric and I are at ucsf, and our trainees, they move between different hospital systems. So, like at UCSF’s main hospital system, there is a pathway for unilateral DNR, you know, and there are specific procedures that you have to follow and discussions and ethics committee consults, et cetera. At the va, as Eric said, there is not. And so our trainees, just within the same training system, they get confused sometimes, and they’re like trying to institute a unilateral DNR in a system where that is not allowed. And we have to do education about that, much less the variation you found across the country and across different systems. Go ahead, Eric.

Eric 11:47

So I understand unilateral dnr. Now, what’s the different types that you put in your paper?

Gina 11:55

Yeah, well, did you want to describe it?

Will 11:58

Yeah, I think the main two types we identified, basically by just analysis and thinking through what are the possible scenarios is in ascent unilateral dnr. That’s that scenario I just described where the clinician comes into the room and says, you know, we are always imagining critical care unit in these settings, so, you know, we are not going to perform CPR. Here’s why. Explain the reasons empathetically, you know, use our best bedside manner, obviously, and the family sort of ascends to that. But they haven’t actually been given the choice about performing CPR or not.

In contrast, a conflict you model DNR is that same scenario, except the family says, no. I reject your reasoning. I want my loved one to receive CPR. You have to do it. And so the latter one, I think, is what most people think of when they say this is a unilateral dnr. But part of what we’re trying to argue in the paper is that the ascent unilateral DNR is equivalent in many ethical respects.

Eric 13:08

How so? Because, like, I feel like this happens all the time. Like, hey, we’re stopping your Zosyn. Hey, the EEG monitor, we’re pulling off today. We are telling people the plan. They can certainly dissent to it, but this is happening all the time. Like, why? Why are we putting CPR on such a high pedestal that we are asking family members to make this decision when there is no decision? The patient’s dying either way, especially in these unilateral DNRs like it really should be in people where it’s.

Erin 13:44

But are they. I think that’s, that’s a question because.

Eric 13:48

Do we have data?

Erin 13:50

Well, how good are we at prognosticating? Even short term. And so I, I mean I have some experience with this because I work in an institution where we can say walk into a room and make a statement saying that we will not offer CPR with some additional. I think it’s important, important to say that the choice architecture here matters and that giving the family space and time and a supportive environment to voice opposition so that they do have that opportunity.

I think it’s critical that we not just plow over them with that recommendation, but we actually give them the time and space to react. But that said, I work in an institution where if there is opposition to the plan, CPR will be provided. And it’s interesting to hear Will’s description of what happens in a code. I mean a lot of the codes say in the medical icu, the patient’s heart hasn’t stopped, it’s beating, it’s pulseless electrical activity. We can’t feel a pulse.

And so it’s on the continent continuum already. You know, they. So we are trying to. What is return of spontaneous circulation in a code setting? It’s a palpable pulse because our patients already have arterial lines. We can see that they’re, you know. Or if somebody throws an ultrasound probe on you can. There’s still cardiac activity. It’s just that we can’t feel the pulse. And that’s kind of what through acls, that’s what we’re trying to regain a pulse.

Eric 15:27

Can I ask you though, Erin, I’m gonna go back to this, like what’s different about CPR? Cause like many of us will not offer things like dialysis. You know, that’s tricky. Depends on which renal attending is on. But you may not offer things like dialysis. There are other life sustaining treatment, ECMO we don’t even mention 99.999% of the time what’s different about CPR and somebody who looks like it’s not going to be helpful, that we feel like we have to have the family members say I don’t want this versus everything else. Like we’re also bearing the burden on our shoulders.

Will 16:12

I mean I think they’re all life sustaining or circulation sustaining treatments. Like if you’re manually compressing the chest, enforcing blood around the circulation because the pulse has dropped low enough, that’s this, that’s a different way to achieve what VA ECMO does.

Eric 16:27

Yeah.

Will 16:28

Dialysis is, you know, preventing a cardiac arrest from severe acidosis hyperkalemia. So I think, Eric, I think your point is that there are some areas of medicine where life sustaining therapies are withheld unilaterally. Just for cultural reasons.

Eric 16:44

Yeah.

Will 16:45

Not necessarily for ethical ones. Yeah. Historical reasons.

Alex 16:48

Yeah.

Erin 16:48

Medical reasons. Not necessarily. It’s historical. Yeah. Yeah.

Eric 16:53

Gina, what do you think?

Gina 16:55

Well, I think, Eric, to your previous point about, like, do we have data about how often this is happening? We say, like, during COVID we looked at two different hospital systems during COVID and patients in the ICU on vasoactive agents. 3% had unilateral DNR orders placed.

Eric 17:11

And the actual order that said unilateral.

Gina 17:13

DNR at one hospital system. Yes, because they had the order. The other one, it was within the notes. Within the notes. It said that this is what we were doing, but it would be a regular DNR order.

Eric 17:24

3%.

Gina 17:25

3% of patients in the ICU on vasoactive agents during COVID Yeah.

Eric 17:31

Can I ask, do you know how many of those people survived to discharge?

Gina 17:36

One, I believe.

Will 17:37

Oh, yeah. No, that’s an interesting point because, you know, if a patient was not an ECMO candidate. So setting aside ecmo, for example, during COVID they’re on. So. And then the whole ethical decision of who gets ecmo, who doesn’t.

Eric 17:50

Yeah.

Will 17:51

So assuming that the ECMO team’s not gonna do ECMO, if you have a patient who’s prone paralyzed and multiple phase suppressors for severe Covid pneumonia, those are the type of situations where I think CPR could be medically said to be strictly futile. You’d have to flip the patient over when they have code with the cardiac. I mean, it would just. It’s not going to work. But then sometimes those patients would get better and you have to.

Eric 18:14

One did one survived a discharge? Yeah. No.

Will 18:17

And I remember distinctly having a conversation with the family member after having gotten an ascent DNR earlier and saying, well, he’s doing better. Like, we’re able to unparalyze him and supinate him today. So he’s no longer dnr. Right. CPR wouldn’t be strictly feudal. His clinical status has improved. And then his, you know, wife said, oh, thank God I never wanted to be DNR in the first place. And that’s what sort of made me realize that this ascent DNR practice is probably very pervasive across medicine. And, you know, I was. I do it, so.

Eric 18:55

I do it all the time. Um, so I Have a. And we teach this in like vital talk training and communication training is that, you know, relying less on menu options for everything we do in medicine. Like, do you want X or do you want Y? We talk about illness, understanding prognosis, we talk about goals, what’s important, what you’re worried about, what you’re hoping for. And then we align with those goals and make a recommendation. For example, like what I said this week was, you know, it sounds like what’s most important to you is your comfort.

You know, we’re gonna do X, Y and Z to make sure that, you know, in continuing things like your antibiotics, living longer is important. And if things don’t go the way we hope, we’re not gonna do things like send you to the hospital or do CPR. Does that sound okay? Or I’m just gonna say, does that sound right? I’m not giving them menu options. Yeah, that is probably closer to a set. Like they actually have to. Now, like, this is choice architecture. Again, I will have a link to our nudging podcast around choice Architecture, but we’re, we’re nudging people towards agreeing to this. Is that okay?

Erin 20:00

I think you can’t just walk into a room and do that. I think you need to have rapport with the family. You need to know something about the patient and their values and preferences. That’s an important element here, is that you can’t just, you know, hear your sign out rounds in the ICU and be like, boom, that person should be dnr and then go in and have that conversation. That’s what I’m talking about, like kind of the time and the space and developing, you know, investing in the rapport with the family.

Eric 20:26

And I’ve definitely seen that. And it does not go well.

Alex 20:29

Does not go well. You gotta do the relationship first so you, you can talk about the hard things. Then you can talk about pro, shared understanding of prognosis, understand what the goals are in view to that shared understanding of prognosis, and then offer a recommendation. So yeah, it’s a longer process and that’s in our practice of palliative care. It may differ in like emergency medicine, critical care, you know, patients crashing, you’re just meeting them on the floo for the first time and you’re talking to family members who you’d never met before.

That’s a different sort of situation. I also worry about like, I don’t know, I guess want push back on the idea that we should separate the ascent unilateral DNRs and sort of categorize them anywhere near the unilateral DNR, you know, terminology. And maybe that’s because it’s such a part of my practice, and I feel perfectly okay with it. Whereas unilateral DNR is. I think there’s some disagreement, as we can see, ethical.

Eric 21:28

You mean the conflict. Unilateral dnr.

Alex 21:31

And I. I don’t want it to land anywhere near that uncertain ethical territory, to be frank. And I feel like, like, from a patient’s perspective, a lot of times we’re unburdening family members who. They can’t say the words. Like, they just can’t say the words, though they may agree with the underlying principle. And I don’t want to have to be in the position as a clinician to be forcing family members to say the words in order for it to be a true DNR rather than a unilateral ascent dnr.

Erin 21:59

Nor do you want.

Will 22:00

Yeah, I. I agree. I think, like, I don’t. I think this ascent UDNR practice is ethical with some of the guidelines. Erin was. Yeah, guardrails. And Erin was. I don’t know if Gina agrees, so I kind of want to throw it over to Gina about that statement. But, yeah, I don’t think the sent UDNR practice that a lot of us engage in with appropriate guardrails is unethical, but maybe Gina disagrees.

Eric 22:26

Gina?

Gina 22:27

Well, I’ll just say that I think with the framework within palliative care, how we, like, try to assess patient values and preferences and align treatment options with that, it’s still like, there’s a huge power differential between the physician and the patient and the family members. And some patients, families, they don’t feel they have any ability to speak up in those conversations. So I think, you know, what Erin was saying about the relationship building is so important. But with all of this, can I, as a physician, really know the lived experience of the patient and family member in front of me? Can I truly help align?

I can do the best that I can, but I think there are times where I feel, because I have my own lived experience, my own judgments and things, I have seen these unilateral DNRs. So in our study, it all looked like it met criteria. They were, like, strictly futile. Like, CPR could not work in those situations. But I’ve seen outside of that study, practices where a patient is on the floor, not on life support, and they’re doing a unilateral dnr. That patient, you haven’t even tried yet to, you know, flight support for this Guy. So I think it’s these concerns about, like, we’re not just doing unilateral DNRs on people who CPR would not work.

We are doing it on people who we think, you know, I just don’t want to do CPR on this patient. It’s just, you know, my moral distress is so severe that I just can’t do it for this patient. And I think that’s where the real concern is about these unilateral DNR orders and, you know, making sure that we document them so that we are aware of them as a clinical team and the patients and surrogates are aware of it as well. And they can speak up because we aren’t just doing it in these strictly futile cases.

Eric 23:51

But, you know, like the person on the floor, we’re also doing that for a lot of other life sustaining treatment decisions, like dialysis. Like, why, Again, I’m still stuck with like, why CPR?

Gina 24:05

I have an issue with dialysis too.

Erin 24:07

I have an issue when that’s an.

Gina 24:08

Issue, you know, that that’s applied differently to different people. And it’s a real issue. Like, that’s something we should be discussing as well.

Eric 24:16

You have a little data on variation on unilateral dnr, don’t you?

Gina 24:20

Yes. And so for our study, and I want to shout out, because a lot of people help with this paper and Mike Huber, who’s also palliative care, I couldn’t have done it without him as well because he looked at all these statutes with me. We looked at all statutes for all US States and District of Columbia about how do you address unilateral decision making for any form of life support, including dialysis. So for that we found that 49 states, at least somewhere in their statute, they allow clinicians to decline to initiate or maintain at least one form of lysis.

Any treatment which could be dialysis could be CPR, could be ecmo, but they’re all over the place. And what justifies that? Some states it’s like, well, you need to have a medical reason to justify it. Other states, you need to have a reason of conscience to justify it. The medical reasons are all over the place. Some it’s like medically inappropriate. What does inappropriate mean? It needs to be standard of practice. What does standard of practice means? So basically all over the place.

Alex 25:16

And why is that a problem?

Gina 25:18

I think I’ll answer this and I’d love to hear, you know, Erin and Will, what they think. For me, I just want patients, like to be able to have like the best system would be a system where we are uniform in what we’re doing and patients and their family members have a way to advocate for themselves when care potentially doesn’t align with their values and preferences. That, you know, potentially could work for them. I think that there’s so much variety across states. I mean there’s just no way to know really what works. Well, in a way because we don’t have a standardized mechanism for, you know, what we’re doing to begin with.

Erin 25:50

Right.

Alex 25:50

But that patient’s like they’re in that state and states may have different. Like this is like the state’s rights versus federalism issue. It’s not as if they’re trans. I mean maybe it happens rarely as they’re transferring across state lines or maybe they intentionally transfer across state lines. Cause there are different rules in different states, but that’s pretty rare. I guess I push back on the notion that state level variation in and of itself is a problem.

Will 26:15

Well, I, I think the point is it’s arbitrary variation in these rules. Like they’re not. There’s a lot of variation between states because no one has like a clear right answer for these, for these rules about with unilaterally with withholding, withdrawing life support. And I think one thing that Gina articulates quite well in this is that if you are with, you know, if you’re withholding a life sustaining therapy, you better have a clear reason. And that reason can’t be just because the person doesn’t speak English, which is what Gina found in her paper. Um, yeah, we want to know more about that. Yeah, we can talk a little bit about that.

But I think for the d to talk about the dialysis, like when the nephrology attending decides not to offer dialysis, there needs to be clear documentation of why that life sustaining therapy is not being offered. And it could be that the burden of going to dialysis three days a week and this frail patient and all the complications that is expected, that burden is too great to justify the risk of, you know, or the potential benefit rather of actually having their renal failure treated. But you know, you need to own up to that. There needs to be an argument made and an explanation given to why it’s not being offered.

Alex 27:22

So it’s really more the problem. Oh, Erin, go ahead. I know you’ve done thinking about this. I know you have a paper about like state level variegation and surrogate decision making. You’ve done work about variation in allocation of scarce resources during COVID Is it the variation That’s a problem. Or is it that sloppy sinking in some of the states?

Erin 27:40

It’s the arbitrariness that Will is saying. If we could prove that they reflected principled differences that reflected the populace of those particular states, I don’t think I would be troubled by it. But these aren’t, you know, these aren’t distillations of the values of the people of one state versus another. Or at least we have no, we have no reason to think that the variation we’re seeing here reflects in some way community engagement or even really, maybe even medical communities engagement around these topics. They just look pretty arbitrary.

And you know, when the decision to withhold a life sustaining therapy hinges on a clinician’s interpretation, many of these don’t even have oversight mechanisms. So a single clinician’s interpretation of what the standard of care is and they can unilaterally withhold as they see fit. Also, we haven’t talked about qualitative futility assessments and what goes into those assessments. So there are a lot of different ways in which there are opportunities for clinicians who wield so much power in this, in this overall dynamic to withhold a therapy that would be desired by a family. And it may, however slim the chance that may have some hope of helping the patient survive the hospitalization.

Eric 29:16

Can I ask. We were talking about statewide variation, Gina. It was alluded to that there may be variation amongst which populations get unilateral DNRs.

Gina 29:28

Yeah. So during COVID that study where we looked at two different academic medical centers, patients who are Spanish speaking were much more likely to have unilateral DNR orders placed compared to their similarly ill patients in the icu.

Eric 29:42

Do we know why?

Gina 29:43

Well, we had some hypotheses. You know, one is, and I know like the teams there, like people were trying the best that they could to try to reach families sometimes it could have been that they couldn’t just reach the family, so they put the order in. Other times, I think, you know, trying to get an interpreter on the line, we weren’t doing in person interpreters back then. Like they were virtual. So I think it probably was a language barrier. But I will say that in my experience, I saw similarly ill patients who would have qualified for a unilateral DNR order who were not Spanish speaking and they did not have it placed.

Eric 30:11

Yeah, we’re humans and we’re biased.

Gina 30:14

Yes.

Eric 30:15

I’m going to go back to conflict. Unilateral DNRs. Is it reasonable to have them, Gina? Is it ethical to have them.

Gina 30:24

I think for a patient who there truly is no way CPR is going to medically benefit them, it is truly physiologically futile. I think the honest thing for physicians to do is to tell the patient and family members, I am so sorry, CPR cannot work. This is all the other things that we are going to do to help support you, but this one thing will not work for you. I think we need to be telling the truth. The alternative, Eric, is we’re going to slow code them.

Erin 30:51

Right.

Gina 30:52

Which is not a good. I mean, in my opinion, it’s not a good option. But I think for those situations, I think it is better to tell the truth and not do CPR than to lie and to do CPR on a patient that we know it’s not going to have a medical. It cannot medically work for them.

Erin 31:09

Yeah.

Eric 31:10

What if the family still wants CPR? Because there will be the family that still wants CPR.

Erin 31:17

I am in favor of a short code, a real code, but maybe it’s not a code that lasts 35 or 40 minutes.

Eric 31:25

You call it when you think it’s no longer beneficial. Again, that’s what happens in like the VA system. You call it when it’s no longer. That’s what should happen.

Will 31:35

You know, I think a lot of families who are requesting that really want full gas, life support and critical care treatment up up until the line. Right. That this assurance that you’ve really done everything possibly could for the patient that has a probability of success. So we know that patients who have DNR orders are less likely to get other aggressive treatments that may have benefit. So I think in my.

Particularly on the south side of Chicago, there’s a lot of earned distrust of the health healthcare system. I think that’s where it comes from is that if I make them dnr, they’re not going to try to save him. They’re just going to let him die. And so I think walking up to the line with families, in my experience, allows us to reach consensus on no CPR. When they sort of establish that rapport and they see that we’ve gone to the mat for the patient and tried everything that was reasonable, do you feel.

Eric 32:30

Like they want us to go up to the mat or you feel like it’s part of their advocacy? They need to advocate for us to go up to the map.

Will 32:37

I think they want their loved one not to die and.

Eric 32:39

Yeah, right.

Will 32:42

I mean. Right. And there are families who, for very good historical reasons, are mistrustful that.

Alex 32:48

That.

Will 32:48

That their loved one is getting that Treatment, the, the, the state of the art treatment, even if you are in an elite academic center because of the types of biases that Gina has described in her work. So yeah, I think they, you know, it’s this idea that they’re gonna, we’re gonna let their patient die so then we can take their organs and give them to our rich patients. You know, like those ideas exist. And I think the only way to, to counteract that is really to be present with the patient and in the critical care unit. That means like being at the bedside trying a lot of different critical care things. Yeah. So that’s, that’s how you, to get.

Erin 33:24

Back to your question about like the ethics of all of this. I think there are circumstances where, you know, the ascent UDNR is unethical and I think there are circumstances where it’s ethical. It’s all in the way that it is that the strength of that conversation. I personally don’t believe in conflict udnr. I’ve never practiced in a place where that was possible. And I, I question our ability to even predict these short term outcomes. And the reason why is that I have colleagues who will try really hard to walk a family through an ascent udnr. The family wants to continue with keeping the patient full code. The patient loses a pulse. And so a lot of people, a lot of smart people think that ROSC would have been strictly physiologically futile. And the patient regains a pulse after five minutes of resuscitation.

Alex 34:25

Yeah.

Erin 34:26

So, you know, like we need to be really strict and really disciplined with our use of the word futility and acknowledge when it is a qualitative judgment versus when it’s really a physiologic judgment. Because sure. The case, the prone patient who was on three vasoactive.

Will 34:44

Yeah.

Eric 34:45

Basically getting coded already hard.

Erin 34:48

Yeah. I mean like that’s, that’s a situation that we see sometimes. But then there are other situations where the outcome wouldn’t be quite as, as perfectly predictable. And, and yet there is real strong arming to try to achieve a certain outcome of code status. Again, this gets back to kind of the culture around the default CPR for every person falls in, in the United States, falls ill in the United States. But that, that’s the culture that we’re working within.

And so I have seen these patients who in any other institution would actually have been made DNR unilaterally who regain a pulse and sometimes they also survive the hospitalization. But if we’re talking about, as Will said at the beginning, what’s the, what’s the objective, the medical objective of CPR is to regain spontaneous circulation, return of spontaneous circulation. And sometimes these patients who wouldn’t have received CPR in another institution do have ROSC and do survive.

Eric 36:00

So I gotta ask another question because your article poses something that I’ve. I’ve never heard before. Again, we’ll have link to this article that was published, I think, January of last year, addressing inadequate documentation of unilateral DNR orders. So, Gina, I’m going to ask you, is that you argue that current documentation, like even if you can do unilateral DNR orders from a conflict perspective and all. Well, sounds like a lot of us use ascent unilateral DNRs. What’s wrong with how we currently document it in our EHRs electronic medical records?

Gina 36:36

I think the concern is kind of, you know, when these patients actually do improve, if you just put a regular DNR order in the chart, you don’t know who consented to that. Did the patient. Was that the patient’s preferences to begin with or were the patient’s preferences always for full code? And the doctor was the one that decided for the DNR order? So I think there’s multiple reasons why it’d be great to have good documentation, but one of the big ones is for that patient who improves. We need to readdress it. And I feel like the only way that we can know to readdress it is in order.

If you wrote in your note and you’re like palliative care note or critical care note, you know, one day, like we’re doing a unilateral DNR order for this, for this reason, who’s going to look back weeks notes, you know, weeks in the past to find that explicit note that said that it’s just so likely to get lost. That’s what having it as an order. And I’ve seen in practice at one institution, I’ve seen the unilateral DNA order as a true distinct order.

Eric 37:32

It’s an order that’s in the chart.

Gina 37:34

Yes, and part of it. The benefit of the order being there is it also has. This institution requires specific things to be met that you must tell the patient.

Erin 37:43

And surrogate that you’re putting it in.

Gina 37:45

And so this order requires you to say that you did those things in order to sign the order. So it kind of is protective in that way as well.

Eric 37:51

Is that true? Conflict and ascent unilateral virus, just conflict.

Gina 37:56

That would be the ideal cause. I think it’s important to know, like, was there conflict behind this But I also think it’s important to know what were those patients values? Number one, that is what we are here for. What are those patient values? That’s, that should be documented somewhere.

Eric 38:11

But we don’t do that for other things. Like we don’t have a U zosin order. Like we should always be rethinking all of the orders that we put in. And even if a patient wants us to start an antibiotic, we don’t think it’s going to be beneficial. Like we’re not going to put in like a again and well, I don’t.

Alex 38:29

Know, Eric, I’ll push back on you about that. Oftentimes as a palliative care team, we discuss code status at the end of a long family meeting conversation. We’ve gotten to know them, make a recommendation, we agree on DNR or they assent to dnr, and then we’re like, oh, please don’t readdress this with the family. We don’t want the primary team to readjust this with the family. We don’t want like some like ER doc who’s just meeting him for the first time to say, hey, if your heart stop, would you like us to initiate chest compression?

Will 38:59

Would you like us to restart it?

Eric 39:01

Yeah.

Alex 39:04

No, there is some like, I don’t know, do we really want this? We want it readdressed thoughtfully at the right time. Is that going to happen?

Will 39:12

Yeah, I think the difference between. Go ahead, Erin.

Erin 39:15

Well, we have, we have an obligation, if there has been a unilateral decision that has been foisted on a family, we have an obligation to revisit that as the patient’s disease trajectory plays out. So if the clinicians are accurate in their prognostication, then the patient will die in the hospital probably in pretty short order if, you know, we’re thinking about a measure like a unilateral DNR order.

But if they do not, and this happens all the time, I few survivors are coming out onto the floor and they’re still, there’s a DNR order trailing them and you try to talk to them about it and nobody has any recollection of what the circumstances are. Or they do recall it. And like Will was saying, they’re horrified that it’s still in the chart because yes, there was that one really dark night where it looked like they might not make it through the night, but they turned the corner and they got better.

Eric 40:12

But isn’t that an argument that everybody should be like, we should be readdressing.

Erin 40:15

Code status for everybody, transition to care yeah, definitely. Yeah.

Will 40:21

But I think it’s like the distinction of having a different order would be like this. A standard DNR is one that is consistent with the patient’s values that they have chosen this. You know, they have these red limit lines around what kind of medical care they want. I mean, I always tell the residents the MIC you like, there are a lot of patients who don’t want life support. You don’t see them here in general. Like, sometimes they make it here despite their values and preferences.

But you have to assume if a patient is in the mic, you. They want you to go full gas. And so I think when a DNR appears in the chart, the assumption is made is that it reflects the patient’s values and preferences. But if it’s been. If it wasn’t a set udnr, that may not be true. And so that’s, I think, what. One of the important points and I think the difference between a CPR and life support and Zosyn is that it’s sort of the last thing that keeps you alive. Right. You know, strictly fetal Zosyn is not gonna. Not gonna prolong your physiologic life at all. But CPR, ecmo, and dialysis will.

Eric 41:23

Will. Is the opposite. True. Like, we have a full code order in our chart. Should we have a unilateral or default full code order just to highlight that we have not yet figured out whether or not this full code order is.

Will 41:38

Oh, yeah, it says assume full in ours.

Alex 41:42

Assume full.

Erin 41:44

Yeah.

Will 41:44

Yeah. Not verified. Not known to be consistent with the patient’s values. No one’s in that conversation.

Eric 41:50

And then it’s unfortunately when someone actually puts the order in for full, which… sometimes

Will 41:53

I love it because just keep. Continues to assume full.

Eric 41:58

You gotta do another article on that.

Will 42:02

Mike Huber created that. Who we referenced earlier, care position at University of Miami. So. But yeah, that’s our. That’s the way it works at University of Chicago to reflect that. But I think that it’s the default because, you know, if you don’t do CPR, then the patient will die. Right. If they suffer, you know, a cardiac arrest or pa. So I think. I think that’s why the paradigms evolve. It’s not that complicated. But yes, we have this soon fall.

Erin 42:27

We don’t have it as an order, but anytime we write admission notes, we write presumed or like, must confirm or whatever to make sure that people know, you know, that we haven’t been able to reach family or we haven’t been able to Discuss it with the family. So absolutely the same. The same principles apply.

Eric 42:44

Okay. Erin, the other thing that I loved about your article, which I’d never thought about before, so you’re kind of against conflict UDNRs, it sounds like there’s this question about that you brought up in your article, all three of you, about whether or not UDNR orders will normalize unilateral DNRs.

Erin 43:03

Tell me that came from me.

Eric 43:06

Did.

Alex 43:08

Did.

Erin 43:09

Yeah, well, because I think it’s exactly that concern. Is there a slippery slope that once people realize this is part of the admission order set? And boy, look at how sick this patient is and how much they’ve already been through. Wow. I can just say that we aren’t going to give the patient CPR and we can save the team the moral distress of offering a therapy that could be hard, you know, that could break their ribs. I’m worried that it would be used and abused and then it might also. Again, getting back to. Gina’s already demonstrated empirically that it’s used differentially for different populations.

Eric 43:50

Gina, are you worried about it?

Gina 43:52

I’m very worried about it, but I think. I mean, it’s already happening in practice. I just feel like we should just focus on helping to make this better. It’s happening in practice. We disagree about whether it should be done or not, but what is being done? Like, we need to do something about it. And I feel like we’re really not addressing it. We’re just like, letting it happen. And there it goes. And that’s not great.

Eric 44:12

Yeah. It is interesting, though, that we don’t put reasoning behind any other order. An order is just an order. Right. For pharmacy meds, we have, like, indication of when to give a prn, but there’s no how we came up with the order process intention to any other order. Is that right?

Will 44:30

Yeah, I think it’s like, for. In the icu, we do like, tons of things to the patient in rapid fire. Right. Without consenting each individual treatment. I think the standard ethical theory is that they’ve consented to the ICU care as a package. They may not be consenting to each individual item, but, you know, they’re. They’re in for a general course of. Critical of life support treatment, and then.

Eric 44:52

They give you default pathway that they’re in until. True. Yeah. So there’s a nudge.

Will 44:57

Yeah. We may not. We may not have. We may not have gotten that general consent for life support. But, you know, I think that’s at least the theory is why you don’t have to get micro might have these discussions about every little detail.

Erin 45:09

And I mean to borrow from our mentor, Dr. Siegler, we err on the side of life until we know more about the situation. So yes, the patient, once they’re admitted to the icu, they’re kind of on a path to receive lots of different interventions until we hear otherwise from them. But that doesn’t mean that we don’t check in with them very regularly about how this aligns with what they expected or hoped for. So they there are many exit ramps short of getting to the end where we’re talking about a unilateral order not to resuscitate.

Eric 45:40

All right, my last question to all three of you. If you had a magic wand, you could change one thing around our healthcare system or what healthcare providers do around DNRs. Unilateral DNRs, what would you use that magic wand on?

Will 45:54

Erin?

Erin 45:55

I guess I’ve already kind of said that my biggest concern is around the definition and looseness with which we throw around the word futility and that it ties in very neatly with my concerns around unilateral DNR orders. So being really strict and precise about using that word for physiologic reasons and only in the most dire cases and.

Eric 46:19

Not like qualitative futility, I don’t think their life is good enough to do.

Erin 46:24

Who am I to say or quantitative.

Eric 46:26

Like what number do what what how low of an odds that who am.

Erin 46:31

I to just because I went to medical school, why do I get to make that judgment?

Will 46:35

Yeah, well, yeah, I think documentation of reasoning for withholding of life support therapies would help. You know, when a surgeon makes a decision not to take that patient with acute abdomen in the or.

Eric 46:47

Yeah.

Will 46:47

They’ve got a whole long note about why they’re not doing it. And you may not, you may not agree with the reasoning all the time, but it’s there. So I think for too many life sustaining therapies, they’re withheld without an explicit justification for why.

Eric 47:02

Yeah, I love that. And maybe making it a place where people can find it like a special life sustaining treatment.

Gina 47:08

No, Gina, I would say in addition, that when these orders are placed and it’s a law by hospital policy, state law, that we really focus on supporting the patients and families through this, make sure that we’re transparent and allow them to have the advocacy that they should have when these decisions are made.

Eric 47:25

Can I ask you a quick question? Texas has a pretty lengthy statute around this, right. That there is is that Like a model you think?

Gina 47:35

I love. When I saw Texas, I thought this is fantastic. But is it actually being used When I’ve talked to people and I’d love, you know, to hear feedback from people, act actually in Texas, I’ve heard like, there’s very limited, like actual reporting of this data happening, but it looks like a great model because there’s like a.

Eric 47:49

10 day period that they can find different, different institutions to care for them.

Alex 47:54

It’s well thought out.

Eric 47:55

Yeah. Well, maybe that’s saved for another podcast. Any Texans listening? If you want to do another podcast on that, let us know. But maybe we’ll just end with a little bit more of heartbreaker. Heartbreaker.

Alex 48:12

(singing)

Eric 49:03

Wonderful. Will, Erin, Gina, thanks for being on the podcast. That was wonderful.

Erin 49:07

Thanks so much for having us.

Eric 49:09

Thank you and wonderful article. We’ll have links to it on our show notes and to all of our listeners. Thank you for your continued support.

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