Dealing With DNR Misinterpretation

Health Care Management "Culture eats strategy." The Business Case for Evidence-Based Management Management literature across all disciplines points to the critical importance of quality decision-making. A fundamental practice problem for decision makers is that the information that is readily available or accessible may be incomplete, outdated, and/or not based on evidence. Quality decision-making is dependent on access to and use of quality information. That is to say that, the old adage used by the early computer scientists -- "garbage in, garbage out" -- is applicable to management decision-making.

This tenet is pivotal to management in healthcare for reasons that span the high stakes patient care decisions to the survival of medical institutions in a punishing fiscal environment. In the service-oriented organizations of healthcare, decisions are part of an interwoven network -- a fabric that encompasses the administrative, operational, and patient care aspects as a unified entity. Poor decisions made in any single business or care unit in a healthcare facility can create waves of repercussions that are felt throughout the institution.

In their review of the Shewhart Plan-Do-Study-Act cycle and the generic eight-step decision-making model, Kovner and Rundall (2006) argue that important considerations are missing from both. The treatment of data gathering and fact finding lacks depth. Decision-making is strengthened when it is derived from a well-rounded and in-depth gathering process that includes data and information from local sources, from current evidence-based best practices, from clinical experience, and is informed by benchmarking to other comparable institutions.

Additionally, Kovner and Rundall (2006) would like to see decision-making models updated to embed the use of information gathered from digital environments, such as the internet and electronic medical records, and the like. An evidence-based approach is typically a five-step process: 1) Identify the research question; 2) access and review the relevant research and evidence; 3) evaluate the relevance, applicability, quality, and validity of the information; and 4) present the findings in a manner that is actionable and persuasive.

Applying this process to the hospital setting, the evidence-based process overlays a root cause analysis (RCA) to this problem of practice. This means that the following questions are asked -- and answered, as much as possible, by providing evidence: 1) What happened? 2) What should have happened? 3) Why did it happen? And 4) What can be done to correct the error? (Percapio, et al., 2008 as cited in Lambton & Mahlmeister, 2010).

Consideration of the Problem In a large academic medical center, it has come to light that patients who have Do Not Resuscitate (DNR) orders sometimes do not receive the level or scope of palliative care that could -- and most likely should -- be provided. Under these conditions, patients suffer needlessly and family members have begun to complain and register unfavorable remarks on websites and social media networks.

As a nurse in the acute care unit, my primary concern related to this matter is that patients at end-of-life are not receiving the quality of care that hospital identifies as central to its mission. The purpose of this discussion is to identify the network of variables that create and sustain the problem, and to provide evidence-based practice solutions to change and manage the situation.

The members of the hospital staff have expressed concern that the problem seems to stem from hospital procedures and from the unconscious cultural bias related to patients who are near death. Hospital procedures may delay the receipt of palliative care and DNR orders do not make the wishes of patients and family members sufficiently salient to hospital staff. Moreover, an underlying attitude of fatalism seems to pervade the acute care unit when a patient is identified as being at end-of-life.

And, too, medical personnel are working at maximum capacity in their dual roles as clinicians and teachers. The problem stems from the root cause of "do-not-resuscitate" orders often being misinterpreted more restrictively than just not providing cardiopulmonary resuscitation, which is most cases was the original intent. The research literature on this topic shows that it was identified about 20 years ago (Henneman, et al., 1994).

The research shows that "do-not-resuscitate" is often misinterpreted more restrictively than just not providing cardiopulmonary resuscitation; this was true even when the patients were otherwise receiving aggressive medical management (Henneman, et al., 1994). The research indicated that misinterpretation of DNR orders may result from poor understanding of hospital policy, the cultural values of hospital staff, and lack of comfort discussing the matter with family members (Henneman, et al., 1994).

Research has shown that end-of-life care in acute care and nursing home settings are often associated with unmet needs such that patients experience pain and both the patient and the family experience emotional and spiritual distress. Chen et al. (2014) found that when medical care provided to DNR patients is clearly indicated, healthcare professionals do not blindly decrease medical care, which was the pre-experimental condition, but will instead provide the medical care determined by patient and surrogate decision-makers and healthcare professionals.

In addition to the practice problem of poor symptom recognition and management, iatrogenic suffering may be commonly experienced by patients who endure procedures that no longer benefit dying patients, but instead adds to their pain and suffering at end-of-life. A set of care guidelines known as the Comfort Care Order Set (CCOS) was devised according to best practices of care for people at end of life (2013).

As such the CCOS guides clinicians to ensure that patients have adequate access to medications for control of symptoms and that processes of care are modified to meet the needs of the patient at the time of treatment or care. By shifting to a comfort care order set (CCOS) approach, disease-managing therapies and palliative care can be continued. While applying the CCOS, practitioners can also weigh the application of restrictions, ordering more tests and treatments if the burdens overshadow the benefits.

Adopting the CCOS can enhance both the quality and quantity of life for patients,.