Advanced Care Planning: Code Status Objectives Background : The problem
Alexander, James, Operations Manager has reference to this Academic Journal, PHwiki organized this Journal Advanced Care Planning: Code StatusTravis NesbitUcimc im pgy-1Minilecture 1/15/2015ObjectivesUnderst in addition to Advanced Care Planning (ACP) Terminology Utilize a POLST to better underst in addition to Code StatusPOLST is not required to make code decisions/orders! Work 3 Example Cases Gain confidence in leading ACP discussionsBackground: The problemCode Status discussion happens as long as every hospitalized patient. Patients / families often confused by the terminology. Physicians also often confused by the terminology.
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Background: Why its importantIncreased likelihood patients wishes are respected. Reduced end-of-life hospitalization. Reduces decision-burden of family members. Reduces moral distress among health care providers.ACP Terminology: OverviewPart 1: DocumentsQuestion: what are two major ACP documents Part 2: AcronymsQuestion: what are 4 major ACP acronymsACP Documents: Advanced Directive>= 18 yrs of age future treatment Appoints a Health Care Representative Does not guide emergency medical personnel Does guide inpatient treatment decisions
ACP Documents: POLSTPhysician Orders as long as Life Sustaining Treatment serious illness at any age current treatment Does guide emergency medical personnel Guides inpatient treatment decisions Can serve as model as long as inpatient Code Discussion! POLST Sections A-CAccessing ACP DocumentsCA Government approved Advanced Directive:http://ag.ca.gov/consumers/pdf/AHCDS1.pdf Search terms (Google): Cali as long as nia Advanced Directive CA Government approved POLST:http://www.cdph.ca.gov/programs/LnC/Documents/MDS30-ApprovedPOLSTForm.pdf Search terms (Google): Cali as long as nia POLST
ACP AcronymsDo Not Resuscitate (DNR): Do not attempt to per as long as m CPR or any other life-restoring measures. Do Not Attempt Resuscitation (DNAR): Synonymous with DNR Allow Natural Death (AND): Definitions appear to vary; CA State approved POLST uses it synonymously with DNR/DNAR. Do Not Intubate (DNI): Do not intubate under any circumstance, code or not.Hypothetical Case 1Mr. A is a 30 yr M with asthma presenting with PNA. He is speaking in full sentences, but appears fatigued in addition to his ABG shows a pCO2 of 50. Dr. K is a 28 yr resident who skillfully elicits a full-code status from Mr. A. Hypothetical Case 1 cont.Question 1: How would you document this decision in the chart Question 2: Although it’s unnecessary in this instance, if you were to fill out a POLST which sections would you check off Question 3: Would you consider filling out a POLST as long as this patient
Hypothetical Case 2Mrs. Jones is also a 96 yr F with h/o 4V CABG, DM2, dementia, multiple pressure ulcers, also presenting from SNF as long as AMS/fever. She was also admitted by ED to MICU as long as Septic Shock; she is protecting her airway, but delirious. She comes with an advanced directive identifying her son Gomer as her decision maker. Dr. K this time is told by Gomer that his mom wouldnt want to be brought back after she passed, but if she needed a breathing tube in addition to it could be removed thats okay.Hypothetical Case 2 continuedQuestion 1: How would you document this Question 2: If we couldnt find manual BP by cuff, in addition to tele showed wide complex polymorphic tachycardia to 200 bpm would you call a rapid response or a code Question 3: Is this patient okay to intubate in a rapid response What about in a code Question 4: Would you consider filling out a POLST as long as this patientHypothetical Case 3Mrs. Daisy is a 114 yr F with h/o 4V CABG, DM2 s/p bilateral amputations, prosthetic hip, multiple pressure ulcers, presenting from SNF as long as AMS/fever. Admitted by ED to MICU as long as Septic Shock; she is protecting her airway, but delirious. She comes with an advanced directive identifying her son Jeb as her decision maker. Dr. K contacts Jeb. Jeb says she doesnt want to be revived, in addition to no invasive breathing machines under any circumstance.
Hypothetical Case 3 continuedQuestion 1: How would you document this Question 2: If this patient had BP 55/33, confused, tachycardic to 180 bmp, in addition to appeared to have respiratory distress would you call a rapid response or a code Question 3: Is this patient okay to intubate in a rapid response A code Question 4: Would you consider filling out a POLST as long as this patientSummary Know POLST in addition to Advanced Directive Know DNR, DNAR, AND, DNI A code in addition to DNR status is as long as cardiopulmonary arrest. DNR in addition to DNI are separate decisions. DNI applies to all circumstances, not just the code. A POLST can be a good model as long as your code discussion. A code menu is not necessary; see the POLST as an ex.ReferencesState of Cali as long as nia Department of Justice, Office of the Attorney General. http://ag.ca.gov/consumers/pdf/AHCDS1.pdfCali as long as nia Department of Public Health. http://www.cdph.ca.gov/programs/LnC/Documents/MDS30-ApprovedPOLSTForm.pdfUpToDate.com. http://www.uptodate.com/contents/advance-care-planning- in addition to -advance-directivesBrigham in addition to Womens Faulkner Hospital. http://www.brigham in addition to womensfaulkner.org/about-us/patient-visitor-in as long as mation/advance-care-directives/dnr-orders.aspx .VLhu-XvCf8M
Alexander, James Operations Manager
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