THUNDER BAY – HEALTH – A new policy announced today at Thunder Bay Regional Health Sciences Centre (TBRHSC) gives patients greater control over the level of resuscitation they receive in the event of a cardiac or respiratory arrest or unexpected deterioration.
“For many patients, having a conversation about resuscitation preferences and potential outcomes at the time of admission is essential,” says Dr. Will Anderson, Staff Intensivist with the Department of Critical Care Medicine (ICU) at TBRHSC. “Our responsibility is to provide the best possible care within the bounds of what the patient would want and what is medically appropriate. We want our patients and their families to understand the options and the possible outcomes so that they can make informed decisions about their healthcare. This policy is not only best practice, it helps patients and families decide the most appropriate level of resuscitation, the level that is right for them, and ensures their wishes are clearly communicated to their healthcare providers.”
The term ‘Do Not Attempt Resuscitation’ or DNAR was formerly used in this hospital for patients who did not want cardiopulmonary resuscitation (CPR). But this term was unacceptably vague and open to interpretation. The new policy brings greater clarity in the form of five “Code Status Levels”. These five levels reflect what has been the actual clinical practice at TBRHSC for many years. These levels will give patients a better understanding of their options and of the level of resuscitation they will receive should they become unstable or critically ill.
“Probably the greatest benefit to many patients from this new policy is the fact that it mandates a code status discussion with their physician within 24 hours of admission.” says Dr. Anderson. “From this discussion, the patient and their family will be provided with the information they need to make an informed decision.” For some patients, providing CPR or advanced life support will not change their clinical outcome. “Patients and their families want to know the clinical situation, and they deserve to know what will or will not be of benefit to them,” says Dr. Anderson. When there is doubt, their physician can consult other specialists, such as the Critical Care team, for advice and guidance. “Our ICU and Medical Emergency Team are staffed 24/7 and we are here to do the best we can for our patients,” says Dr. Anderson. “It’s all about bringing our patient through their critical illness to an outcome that they would find acceptable.”
“At TBRHSC, our healthcare providers are committed to respecting patients’ wishes to provide personalized care,” says Dr Rhonda Crocker Ellacott, Executive Vice President, Patient Services & Chief Nursing Executive. “No matter which Code Status Level you choose, you will receive exceptional care at TBRHSC.”
Patients or their Substitute Decision Maker will be asked to choose one of the following Code Status Levels, which will identify the level of resuscitation that will be provided in the event of cardiac/respiratory arrest or clinical deterioration.
Level 5: I want all medically appropriate life-sustaining measures.
Level 4: I do not want Cardiopulmonary resuscitation (CPR), but I will accept a medically appropriate trial of intubation and mechanical ventilation including life support.
Level 3: I do not want CPR. I will accept a medically appropriate trial of non-invasive ventilation including life support.
Level 2: I do not want CPR or ventilator support but I want full medical therapy as appropriate
Level 1: I want comfort measures only. I do not want CPR or ventilation. I do not want aggressive medical care. I do not want any prolongation of my life. I want treatment to provide relief of any pain or discomfort I may have.
For patients who are Code Status Level 4 or 3, a blue armband that clearly displays Level 4 or Level 3 will be applied. For patients with a Code Status Level 2 or 1, a purple armband that clearly displays Level 2 or Level 1 will be applied. This ensures that the patient’s resuscitation wishes are communicated to all members of the healthcare team.
On admission every patient will receive a brochure entitled “It’s Your Life” explaining terms such as CPR and Life Support Therapies and offering examples of the available choices. The brochures are meant to provide a basis for discussion with their families and their healthcare providers.
“We encourage patients to talk to their healthcare providers, and to their family members to decide what is right for them,” says Lisa Beck, Director Trauma Program, Critical Care & Emergency Services.
Many volunteer Patient Family Advisors (PFA’s) – patients turned volunteers – were involved in the working group responsible for the new Code Status Level policy and corresponding resources such as the brochure for patients.
PFA Jan Miller says it is very important for individuals to talk to their family members and healthcare providers about the level of resuscitation they would prefer in the event of cardiac/respiratory arrest or unexpected acute cardiac/respiratory distress. “Those are not always easy conversations to have, but is so important in order to ensure that your wishes are known, especially in the event that you are not able to communicate those preferences in hospital.”
For additional information about communicating your future health and personal care preferences in the event that you become incapable of consenting to or refusing treatment or other care, visit www.advancecareplanning.ca.