End-of-Life Palliative Care for Veterans: DNR Order Misinterpretation

Introduction and Problem Statement

The nursing-sensitive quality indicator that is problematic at my place of employment is that veterans who are at the end of life are not receiving the palliative care they need to be comfortable. Two fundamental situations contribute to this practice problem: do-not-resuscitate (DNR) orders that are misinterpreted, and excessive time passing before veterans receive the palliative consult they require. This quality indicator relates to appropriate care at end-of-life or when dying.

Taking a root cause analysis (RCA) approach to this problem of practice, the following questions can facilitate a considered evaluation of the quality indicator: (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). These questions form the framework for a systematic investigation into both the practice problem and evidence-based solutions.

Root Cause Analysis Framework

If veterans are uncomfortable as they are dying—experiencing rapid respirations and overuse of accessory muscles—then it is fair to say that the quality indicator is not being measured appropriately. Moreover, this situation demonstrates poor quality patient care rather than a good reflection of quality. Using the root cause analysis (RCA) as the basis for analysis of the nursing-sensitive quality indicator, the following question-answer format applies.

What happened? Research has shown that end-of-life care in acute care and nursing home settings is often associated with unmet needs such that patients experience pain and both the patient and family experience emotional and spiritual distress. 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 add to their pain and suffering at end-of-life.

DNR Order Misinterpretation and Patient Outcomes

Henneman et al. (1994) identified this issue more than twenty years ago. In their research, they found that "do-not-resuscitate" is often misinterpreted more restrictively than its original intent of simply not providing cardiopulmonary resuscitation—this misinterpretation occurred even when patients were otherwise receiving aggressive medical management. The study identified a variety of factors that can contribute to this misinterpretation of DNR orders, including insufficient understanding of hospital policy, the ethical and moral values of hospital staff, and lack of comfort discussing the matter with family members (Henneman et al., 1994).

The research suggests that clearly defined and jointly determined resuscitation plans that engage the patient, family members, and the multidisciplinary team are essential. Without such clarity, clinicians may apply DNR orders as a blanket restriction on all interventions rather than as a specific limitation on resuscitation efforts alone. This overly restrictive interpretation directly contributes to delayed palliative care consultation and inadequate symptom management.

What should have happened? By shifting to a Comfort Care Order Set (CCOS) approach, disease-managing therapies and palliative care can be continued while simultaneously reducing restrictions, avoiding testing and treatments when the burdens now outweigh the benefits.

The Comfort Care Order Set Solution

Why did it happen? The problem stems from the root cause that "do-not-resuscitate" orders are often misinterpreted more restrictively than their original intent, which in most cases was simply to avoid cardiopulmonary resuscitation.

What can be done to correct the error? Adopting the CCOS can enhance both the quality and quantity of life for patients (Percapio et al., 2008 as cited in Lambton & Mahlmeister, 2010). The Comfort Care Order Set (CCOS) was devised according to best practices of care for people dying in home hospice settings (Watt, 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. The CCOS also fosters the advantageous use of resources available through institutional care.

Chen et al. (2014) conducted a study in which two distinct protocols for DNR orders were used that allowed patients with DNR orders to choose the medical care they preferred. The two options were as follows: DNR Comfort Care (DNRCC), which consisted of patients receiving only comfort care after the DNR order is written; and DNR Comfort Care-Arrest (DNRCC-Arrest), which indicated that patients are eligible to receive aggressive interventions until cardiac or respiratory arrest occurs (Chen et al., 2014). 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. This finding demonstrates that explicit protocols change clinical behavior in measurable ways.