End of Life Decisions (Talking about DNR)

"Do you have advice on talking with patients about Do Not Resuscitate status?"
Here are some thoughts and a helpful reference.

First
Begin a conversation, rather than "get the DNR"

Common Experience
You are in sign-in rounds. Your senior says, "On Mr. G we need to get the DNR." You put it on your list. Later the Attending asks you if you "got the DNR?"

Stepping Back...Pulling up a Chair
Let's step back for a second... Nothing needs to be gotten. Nothing.

What you can do is pull up a chair and talk with that individual patient. You can listen to what they know about their circumstance. What is their understanding of what is going on? What are their goals, their hopes? What is their concept of recovery?

You may have to pull up a chair more than once to hear them out--to give them a sense that you hear them. You can begin a conversation, not necessarily "get" something. It is not for the getting. It is for the patient's considering and deciding. It is for you to hear.

Use the same conversation/interview techniques you use elsewhere. Open-ended questions. Use the patient's words back to them. Point out what you heard them say. Clarify.

Drs. Lo, Quill and Tulsky in this article from the Annals of Internal Medicine give word by word examples of sample conversations, including tables of helpful phrases. This open-ended approach is helpful when eliticing an individual's ideas on resuscitation as well as other end of life decisions, advance directives, withdrawing care, and hospice.

Larger Team
Secondly, you are part of a larger team. This is reassuring. While the command "get the DNR" points to you, relax. This is a human being you will be talking with. And nurses, social workers, spiritual professionals and others are on your team to help you understand that person's wishes. Involve them, chances are they have already begun talking with your patient. So listen to the team too.

Summary Suggestions
Pull up a chair more than once. Hear your patient's understanding. Respond to emotions. Clarify. Give information. Come up with a plan. Involve the team. Listen to the patient.

Continued Learning
This is not a one time "I get it" kind of deal. There is no one way. Objections can be raised to any technique. We all continue to learn about this. You can talk and you can listen. The patient is making choices.

For specific advice take a look at the paper by Drs. Lo, Quill and Tulsky. To see the process broken down into steps, see Drs. Weissman & VonGunten Parts 1 and 2.

Last update: 7/13/02; 11:27:31 PM.