Quality Initiative Honors End-of-Life Preferences

Innovations in Geriatric Medicine | Fall 2021

A quality initiative at University Hospitals Cleveland Medical Center aims to honor patients’ end-of-life preferences for do-not-resuscitate (DNR) status and assure the communication of those preferences across care settings.

Kenneth Rosenfeld, MD

“This project grew from the experience of a senior resident whose patient received CPR, which is the default for situations of cardiac arrest when a patient’s wishes aren’t known,” says Kenneth Rosenfeld, MD, System Director of Palliative Care at University Hospitals. “She was distressed to subsequently learn that the patient had been hospitalized a month prior and had expressed a desire to avoid CPR during that stay.”

In response, Dr. Rosenfeld mentored the resident on a retrospective study of 224 University Hospitals patients who died over a 16-month period (2018-2019) who had expressed a preference for a DNR order and who had subsequently been readmitted to the hospital prior to death. 

Of the 224 decedents:

• 60 percent had at least one subsequent hospitalization with “full code” status
• 89 percent of these “discordant” patients had no documented code status discussion (these are patients whose previously expressed DNR preference was not documented in a DNR order within 48 hours of admission)
• 5 percent (11 patients) received CPR, approximately half of which occurred at the hospital and half outside of the hospital

Respecting Patient Autonomy

First endorsed by the American Heart Association in 1963, closed chest compression was soon considered a technological imperative. In the 1970s, it became the standard of care, and patients had to refuse treatment through a DNR order. In emergencies, CPR saves lives.

However, Dr. Rosenfeld says that much modern hospital care is not delivered to otherwise healthy people who have a sudden cardiac or respiratory event but to people who have progressively worsening disease, advanced organ/system failure or frailty of old age. For this population, CPR is rarely effective at improving survival or discharge outcomes. In patients with advanced cancer, for example, cumulative studies show an approximate seven percent survival-to-discharge rate when CPR is attempted.

Although most patients wish to avoid end-of-life treatments that will not help them recover, discussions about DNR orders are often delayed until very late in the illness course, leaving patients vulnerable to unwanted treatments in the event of rapid decline.

“Given their druthers, most patients would not want burdensome, low-benefit interventions as they approach death,” Dr. Rosenfeld says. “The focus has become, ‘How we can normalize conversations with patients and families that maintain hope while honoring their end-of-life wishes?’”

Harnessing the EMR

To ensure providers are aware of patient preferences, the team is adapting the EMR workflow at hospital discharge and at subsequent hospital admission, should it occur. If a patient has a hospital DNR order, the EMR displays that status in the header and, at the time of discharge, prompts the provider to discuss the patient’s preference to extend their DNR order beyond the hospital stay through a portable State of Ohio DNR order form.  Once the provider documents the form’s completion, the EMR header will alert providers to the state of Ohio DNR form’s presence in case the patient re-presents to the Emergency Department or hospital and their wishes are unknown.

The streamlined EMR process can facilitate code status discussions during subsequent hospitalizations by informing providers of the presence of an Ohio DNR form. “All they need to say is, ‘I see that you’ve completed a portable DNR order,’” Dr. Rosenfeld says.  “‘Would you like that preference to apply here in the hospital?’”

He notes that patients are free to revoke the order at any time.

Buoyed by positive feedback from this initiative, University Hospitals is extending its efforts to ensure that end-of-life preferences are honored.  “As part of our discharge planning, we’re currently building an additional mechanism to ensure that when a patient transitions to a nursing home or sub-acute care facility, their State of Ohio DNR form is also transferred with complete confidence,” Dr. Rosenfeld says.

Moving Forward

Since the quality initiative launched in early 2021, UH physicians have actively engaged in these crucial conversations with patients. “We plan a full evaluation in another six months; our initial audits suggest that this initiative is highly effective,” Dr. Rosenfeld says. “It appears that 80 to 85 percent of patients want their DNR orders extended and are leaving the hospital with an accurate, durable documentation of those preferences.”

To contact the UH Center for Geriatric Medicine, call 216-844-2400.

Contributing Expert:

Kenneth Rosenfeld, MD

System Director of Palliative Care

University Hospitals

Senior Clinical Instructor of Medicine

Case Western Reserve University School of Medicine