Evidence-Based Management and DNR Palliative Care Gaps

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fundamental practice problem for decision makers is that readily available or accessible information may be incomplete, outdated, or not based on evidence. Quality decision-making is dependent on access to and use of quality information. The old adage used by early computer scientists — "garbage in, garbage out" — applies directly to management decision-making. This tenet is pivotal to management in healthcare for reasons that span 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 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, in-depth gathering process that includes data and information from local sources, current evidence-based best practices, clinical experience, and benchmarking against comparable institutions. Additionally, Kovner and Rundall (2006) call for decision-making models to be updated to embed the use of information gathered from digital environments, such as the internet and electronic medical records.

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 approach overlays a root cause analysis (RCA) onto the 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).

Identifying the Practice 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, the primary concern related to this matter is that patients at end of life are not receiving the quality of care that the 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.

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. Medical personnel are also 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 merely withholding cardiopulmonary resuscitation, which in most cases was the original intent.

Root Causes of DNR Misinterpretation and Palliative Care Gaps

The research literature on this topic shows that the problem was identified approximately 20 years ago (Henneman et al., 1994). The research demonstrates that "do-not-resuscitate" is often misinterpreted more restrictively than just not providing cardiopulmonary resuscitation — this was true even when 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 a lack of comfort in 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 is 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 add to their pain and suffering at end of life. The convergence of cultural bias, procedural ambiguity, and inadequate palliative care protocols creates a systemic failure that demands an evidence-based institutional response.

Conclusion

From the research cited in this discussion, we observe that the ordinary misinterpretations of DNR orders and delays in palliative care may be overcome by explicit orders and protocols. There is recognition that end-stage disease and documentation of advance directives are powerful determinants of quality of care for patients in hospitals. Clearly defined and jointly determined resuscitation plans that engage the patient, family members, and the multidisciplinary team are indicated by the evidence and are aligned with the hospital's mission.

References

Chen, Y. Y., Gordon, N. H., Connors, A. F., Garland, A., Chang, S. C., & Youngner, S. J. (2014, August). Two distinct Do-Not-Resuscitate protocols leaving less to the imagination: an observational study using propensity score matching. BMC Medicine, 29(12), 146. doi: 10.1186/s12916-014-0146-x.

Henneman, E. A., Baird, B., Bellamy, P. E., Faber, L. L., & Oye, R. K. (1994, November). Effect of do-not-resuscitate orders on the nursing care of critically ill patients. American Journal of Critical Care, 3(6), 467–472.

Kovner, A. R., & Rundall, T. G. (2006). Evidence-based management reconsidered. Frontiers of Health Services Management, 22(Spring), 3–46.

Lambton, J., & Mahlmeister, L. (2010). Conducting root cause analysis with nursing students: best practice in nursing education. Journal of Nursing Education, 49(8), 444–448.

Percapio, K. B., Watts, B. V., & Weeks, W. B. (2008). The effectiveness of root cause analysis: What does the literature tell us? Joint Commission on Quality and Patient Safety, 34, 391–398.

Watt, R. (2013, May 30). Comfort Care Order Set (CCOS). Comfort Care Order Set Implementation Introduction. Beacon Project.