A Unique Look at Ohio’s Do-Not-Resuscitate Law: Do-Not-Resuscitate Comfort Care-Arrest and Do-Not-Resuscitate Comfort Care* Lisa Anderson-Shaw, DrPH, MA, MSN Clinical Ethics Consult Service University of Illinois at Chicago Chicago, IL n this issue of Critical Care Medicine, the article by Chen et al (1) highlights the use of two different protocols of donot-resuscitate (DNR) orders. These specific DNR protocols are legislated by the State of Ohio and are standard of care for patients who have a DNR order in that state (2). The first proto col is do-not-resuscitate comfort care-arrest (DNRCC-Arrest) and the second is do-not-resuscitate comfort care (DNRCC). The study objective in this article was to compare clinical, demo graphic, and outcome data between patients with DNRCCArrest and DNRCC orders in an ICU setting. The results of this comparison using factors associated with DNR (older age, race, and severe clinical illness on admit to ICU) were similar to previous research published on the same topic (3-5). Explora tion of these two defined protocols by critical care practitioners throughout the United States would be very interesting and per haps would provide clarity to DNR orders in general. A major strength of this study is the authors claim that no previous studies have been published that compares the two DNR protocols used in Ohio. This is im portant as the Ohio’s Do-Not-Resuscitate law was enacted in 1998 (6) and affects many healthcare institutions, providers, and patients in the State of Ohio. The authors define the variables of DNRCC and DNRCC-Arrest very well as many critical care providers may not be familiar to these terms/protocols. The study protocol is also im portant for this study in that all patients were cared for by a single team of physicians and were enrolled in the study by these team members, which helped control for biases related to consistency that can occur in clinical studies when provider team members fre quently rotate in/out or cross cover patient care and may be expected to assist with study subject recruitment. Consis tent care providers may also enhance trust between patient and providers related to end-of-life discussions. End-of-life discussions can be uncomfortable for providers, patients, and family members, especially when the patient is in the
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ICU with a possible life-limiting health issue. Chen et al (1) also note in this study that physicians and other consistent care providers do have an influence on end-of-life decisions by patient and family members as noted in several recent studies as well (7-9). Although one of the strengths to this study is the consistency among provider team members and patient/family members when discussing DNR and end-of-life care treatment options, a major flaw in the study protocol was a lack of criteria for a pro vider team member whether or not to approach a specific patient/ family about the option to participate in this study. The text is not clear as to how providers made the decision to approach a patient /family member about the study inclusion option; however, the authors do state in their Materials and Methods section that the physician on duty was “independently responsible for all care decisions, including DNR decisions” (1) (p. 9). Generalizability of the data really limits the study results not only due to the fact that data was only gathered from one center but perhaps more importantly that the DNR law in Ohio does not represent DNR laws throughout the United States. The authors do point out that their data related to “DNR patients compared to non-DNR patients are similar to several previous multicenter studies (1)”; however, the unique status of their standard DNR protocols is the limiting factor as it relates to only institutions with the same DNR protocols. This study, however, does provide a firm foundation to expand further research comparing the two DNR protocols at multiple sites within the State of Ohio.
REFERENCES 1. Chen Y-Y, Gordon NH, Connors Jr AF: Factors Associated With Two Different Protocols of Do-Not-Resuscitate Orders in a Medical ICU. Crit Care Med 2014; 4 2 :2 1 8 8 -2 1 9 6 2. Ohio Department of Health: Do Not Resuscitate Comfort Care. Available at: http://www.odh.ohio.gov/odhprogram s/dspc/dnr/dnr1. aspx. Accessed April 13, 2014 3. Reynolds KS, Hanson LC, Henderson M, et al: End-of-life care in nursing home settings: Do race or age matter? Palliat Support Care 2 0 0 8 ;6 :2 1 -2 7 4. Tumangday C, Dakwar J, Chawla S, et al: Characteristics and outcomes of DNR patients admitted to an oncologic ICU. Chest 2011 ;140:348A
'S e e also p. 2188. Key Words: critical care; do-not-resuscitate; end of life; intensive care unit; palliative care The author has disclosed that she does not have any potential conflicts of interest. Copyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/C C M .0000000000000466
Critical Care Medicine
5. Bacchetta MD, Eachempati SR, Fins JJ, et al: Factors influenc ing DNR decision-making in a surgical ICU. J Am Coll Surg 2006; 2 0 2 :9 9 5 -1 0 0 0 6. Ohio Revised Code: Chapter 2133: Modified Uniform Rights of the Terminally III Act and the DNR Identification and Do-Not-Resuscitate Order Law. http://codes.ohio.gov/orc/2133. Accessed April 13, 2014 7. Wilson ME, Samirat R, Yilmaz M, et al: Physician staffing models impact the timing of decisions to limit life support in the ICU. Chest 2013; 1 4 3 :6 5 6 -6 6 3
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Editorials 8. Forte DN, Vincent JL, Velasco IT, et al: Association between educa tion in EOL care and variability in EOL practice: A survey of ICU phy sicians. Intensive Care Med 2012; 3 8 :4 0 4 -4 1 2
9. Douglas SL, Daly BJ, Upson AR: Neglect of quality-of-life consider ations in intensive care unit family meetings for long-stay intensive care unit patients. Crit Care Med 2012; 40:461 -4 6 7
Safety in Numbers...Really?* Life is the art of drawing sufficient conclusions from insufficient premises. -Samuel Butler M a u r e n e H arvey, M P H , M C C M
Douglas County, NV ICUs were originally designed as multi-bedded cubicles around a central station. Recently, there has been a trend toward build ing units with private patient rooms. The Guidelines for Design and Construction of Hospitals and Outpatient Facilities that become state regulations in most states require private rooms for medical-surgical units but not yet for critical care areas (1). Benefits of private rooms can include decreased infection risk, increased privacy, decreased sleep deprivation, decreased staff distractions, and increased family satisfaction (2-4). The biggest drawback is the space and costs required for building ICUs with private rooms. However, although it has not been adequately researched, these costs can be mitigated by benefits obtained through improved patient outcomes. Some nurses have reservations about private rooms because they do not believe they will be able to see as many patients at once and will be more isolated from advice and assistance of coworkers when providing patient care. It seems curious that none of us would book or tolerate a motel that expected us to share our rooms with other guests. Regulations recognize the need for privacy for medical-surgi cal patients. Yet, the most vulnerable and critically ill patients in ICU are allowed to be cared for in multi-bedded rooms. More research is required comparing multiple-patient to single-patient rooms in ICU to inform design teams. In this issue of Critical Care Medicine, Caruso et al (4) have made an important contribution. They found that the odds ratio of developing delirium in multiple- versus single-patient rooms was 4.03. ICU delirium is hard on patients, families, and staff and is largely untreatable. Furthermore, it is a strong risk fac tor for postintensive care syndrome (5). Although the study is limited as it was done in an oncology teaching hospital in Bra zil, the results are impressive. It is even more impressive when their delirium prevalence (13%) is considered. In the United States, the prevalence is usually found to be over 50%.
*See also p. 2204. Key Words: art of nursing; delirium; private rooms; safety The author has disclosed that she does not have any potential conflicts of interest. Copyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
DOI: 10.1097/CCM.0000000000000569 23 00
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Previous similar studies comparing single- to multiplepatient rooms have yielded mixed results. One possible reason for the difference found in the study by Caruso et al (4) is the fact that the two multiple-patient rooms had 10 and 13 beds. In many previous studies, the multiple-patient rooms had only 2-4 beds. Another difference in the study by Caruso et al (4) is that their patients were cared for by the same staff, whereas some previous comparisons have been done between units with different staff in different facilities. There is a factor that I am sure is an important confounder of results in critical care research on delirium, anxiety, agitation, pain, stress, sleep, and vital signs: the art of nursing. It can be a powerful therapeutic intervention. We have all observed great differences in the way ICU nurses deliver patient care. At their best, nurses treat patients with respect and compassion. They use eye contact, caring touch, reassurance, and quiet explanations of what is being done. They handle patients gently and try to cause as litde pain and distress as possible. They take the time to make the patient comfortable, identify their individual needs, and cre ate a healing environment. At their worst, nurses do not do seem to recognize the patient as a person and simply perform the tasks required. They are not as caring or gentle and can inflict great patient distress as a result. Although the art of nursing is described in broad terms in the literature, no tool exists to measure it (6-8). It would be difficult to create such a tool but that is not a good reason for not doing so. I believe measuring the art of nursing as a variable in many studies would decrease the variability in out comes and make a great contribution to care of the critically ill.
REFERENCES 1 . The Facility Guidelines Institute: Guidelines for Design and Construction of Hospital and Outpatient Facilities. Chicago, IL, Facility Guidelines Institute, 2014 2. Thompson DR, Hamilton DK, Cadenhead CD, et al: Guidelines for intensive care unit design. Crit Care Med 201 2; 40:1 5 8 6 -1 600 3. Hamilton DK, Shepley MM: Design for Critical Care: An EvidencedBased Approach. Boston, MA, Elsevier, 2010 4. Caruso P, Guardian L, Tiengo T, et al: ICU Architectural Design Affects the Delirium Prevalence: A Comparison Between Single-Bed and Multibed Rooms. Crit Care Med 2014; 4 2 :2 2 0 4 -2 2 1 0 5. Needham DM, Davidson J, Cohen H, et al: Improving long-term out comes after discharge from intensive care unit: Report from a stake holders' conference. Crit Care Med 2012; 4 0 :5 0 2 -5 0 9 6. Almerud S, Alapack RJ, Fridlund B, et al: Caught in an artificial split: A phenomenological study of being a caregiver in the technologically intense environment. Intensive Crit Care Nurs 2008; 2 4 :1 3 0 -1 3 6 7. Jasmine T: Art, science, or both? Keeping the care in nursing. Nurs Clin North Am 2009; 4 4 :415 -42 1 8. Morton PG, Fontaine DK: Critical Care Nursing: A Holistic Approach. Tenth Edition. Philadelphia, PA, Lippincott Williams and Wilkins, 2013 O ctober 2014 • Volume 42 • Number 10
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
I
ICU with a possible life-limiting health issue. Chen et al (1) also note in this study that physicians and other consistent care providers do have an influence on end-of-life decisions by patient and family members as noted in several recent studies as well (7-9). Although one of the strengths to this study is the consistency among provider team members and patient/family members when discussing DNR and end-of-life care treatment options, a major flaw in the study protocol was a lack of criteria for a pro vider team member whether or not to approach a specific patient/ family about the option to participate in this study. The text is not clear as to how providers made the decision to approach a patient /family member about the study inclusion option; however, the authors do state in their Materials and Methods section that the physician on duty was “independently responsible for all care decisions, including DNR decisions” (1) (p. 9). Generalizability of the data really limits the study results not only due to the fact that data was only gathered from one center but perhaps more importantly that the DNR law in Ohio does not represent DNR laws throughout the United States. The authors do point out that their data related to “DNR patients compared to non-DNR patients are similar to several previous multicenter studies (1)”; however, the unique status of their standard DNR protocols is the limiting factor as it relates to only institutions with the same DNR protocols. This study, however, does provide a firm foundation to expand further research comparing the two DNR protocols at multiple sites within the State of Ohio.
REFERENCES 1. Chen Y-Y, Gordon NH, Connors Jr AF: Factors Associated With Two Different Protocols of Do-Not-Resuscitate Orders in a Medical ICU. Crit Care Med 2014; 4 2 :2 1 8 8 -2 1 9 6 2. Ohio Department of Health: Do Not Resuscitate Comfort Care. Available at: http://www.odh.ohio.gov/odhprogram s/dspc/dnr/dnr1. aspx. Accessed April 13, 2014 3. Reynolds KS, Hanson LC, Henderson M, et al: End-of-life care in nursing home settings: Do race or age matter? Palliat Support Care 2 0 0 8 ;6 :2 1 -2 7 4. Tumangday C, Dakwar J, Chawla S, et al: Characteristics and outcomes of DNR patients admitted to an oncologic ICU. Chest 2011 ;140:348A
'S e e also p. 2188. Key Words: critical care; do-not-resuscitate; end of life; intensive care unit; palliative care The author has disclosed that she does not have any potential conflicts of interest. Copyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/C C M .0000000000000466
Critical Care Medicine
5. Bacchetta MD, Eachempati SR, Fins JJ, et al: Factors influenc ing DNR decision-making in a surgical ICU. J Am Coll Surg 2006; 2 0 2 :9 9 5 -1 0 0 0 6. Ohio Revised Code: Chapter 2133: Modified Uniform Rights of the Terminally III Act and the DNR Identification and Do-Not-Resuscitate Order Law. http://codes.ohio.gov/orc/2133. Accessed April 13, 2014 7. Wilson ME, Samirat R, Yilmaz M, et al: Physician staffing models impact the timing of decisions to limit life support in the ICU. Chest 2013; 1 4 3 :6 5 6 -6 6 3
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Editorials 8. Forte DN, Vincent JL, Velasco IT, et al: Association between educa tion in EOL care and variability in EOL practice: A survey of ICU phy sicians. Intensive Care Med 2012; 3 8 :4 0 4 -4 1 2
9. Douglas SL, Daly BJ, Upson AR: Neglect of quality-of-life consider ations in intensive care unit family meetings for long-stay intensive care unit patients. Crit Care Med 2012; 40:461 -4 6 7
Safety in Numbers...Really?* Life is the art of drawing sufficient conclusions from insufficient premises. -Samuel Butler M a u r e n e H arvey, M P H , M C C M
Douglas County, NV ICUs were originally designed as multi-bedded cubicles around a central station. Recently, there has been a trend toward build ing units with private patient rooms. The Guidelines for Design and Construction of Hospitals and Outpatient Facilities that become state regulations in most states require private rooms for medical-surgical units but not yet for critical care areas (1). Benefits of private rooms can include decreased infection risk, increased privacy, decreased sleep deprivation, decreased staff distractions, and increased family satisfaction (2-4). The biggest drawback is the space and costs required for building ICUs with private rooms. However, although it has not been adequately researched, these costs can be mitigated by benefits obtained through improved patient outcomes. Some nurses have reservations about private rooms because they do not believe they will be able to see as many patients at once and will be more isolated from advice and assistance of coworkers when providing patient care. It seems curious that none of us would book or tolerate a motel that expected us to share our rooms with other guests. Regulations recognize the need for privacy for medical-surgi cal patients. Yet, the most vulnerable and critically ill patients in ICU are allowed to be cared for in multi-bedded rooms. More research is required comparing multiple-patient to single-patient rooms in ICU to inform design teams. In this issue of Critical Care Medicine, Caruso et al (4) have made an important contribution. They found that the odds ratio of developing delirium in multiple- versus single-patient rooms was 4.03. ICU delirium is hard on patients, families, and staff and is largely untreatable. Furthermore, it is a strong risk fac tor for postintensive care syndrome (5). Although the study is limited as it was done in an oncology teaching hospital in Bra zil, the results are impressive. It is even more impressive when their delirium prevalence (13%) is considered. In the United States, the prevalence is usually found to be over 50%.
*See also p. 2204. Key Words: art of nursing; delirium; private rooms; safety The author has disclosed that she does not have any potential conflicts of interest. Copyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
DOI: 10.1097/CCM.0000000000000569 23 00
w w w .c c m jo u r n a l.o r g
Previous similar studies comparing single- to multiplepatient rooms have yielded mixed results. One possible reason for the difference found in the study by Caruso et al (4) is the fact that the two multiple-patient rooms had 10 and 13 beds. In many previous studies, the multiple-patient rooms had only 2-4 beds. Another difference in the study by Caruso et al (4) is that their patients were cared for by the same staff, whereas some previous comparisons have been done between units with different staff in different facilities. There is a factor that I am sure is an important confounder of results in critical care research on delirium, anxiety, agitation, pain, stress, sleep, and vital signs: the art of nursing. It can be a powerful therapeutic intervention. We have all observed great differences in the way ICU nurses deliver patient care. At their best, nurses treat patients with respect and compassion. They use eye contact, caring touch, reassurance, and quiet explanations of what is being done. They handle patients gently and try to cause as litde pain and distress as possible. They take the time to make the patient comfortable, identify their individual needs, and cre ate a healing environment. At their worst, nurses do not do seem to recognize the patient as a person and simply perform the tasks required. They are not as caring or gentle and can inflict great patient distress as a result. Although the art of nursing is described in broad terms in the literature, no tool exists to measure it (6-8). It would be difficult to create such a tool but that is not a good reason for not doing so. I believe measuring the art of nursing as a variable in many studies would decrease the variability in out comes and make a great contribution to care of the critically ill.
REFERENCES 1 . The Facility Guidelines Institute: Guidelines for Design and Construction of Hospital and Outpatient Facilities. Chicago, IL, Facility Guidelines Institute, 2014 2. Thompson DR, Hamilton DK, Cadenhead CD, et al: Guidelines for intensive care unit design. Crit Care Med 201 2; 40:1 5 8 6 -1 600 3. Hamilton DK, Shepley MM: Design for Critical Care: An EvidencedBased Approach. Boston, MA, Elsevier, 2010 4. Caruso P, Guardian L, Tiengo T, et al: ICU Architectural Design Affects the Delirium Prevalence: A Comparison Between Single-Bed and Multibed Rooms. Crit Care Med 2014; 4 2 :2 2 0 4 -2 2 1 0 5. Needham DM, Davidson J, Cohen H, et al: Improving long-term out comes after discharge from intensive care unit: Report from a stake holders' conference. Crit Care Med 2012; 4 0 :5 0 2 -5 0 9 6. Almerud S, Alapack RJ, Fridlund B, et al: Caught in an artificial split: A phenomenological study of being a caregiver in the technologically intense environment. Intensive Crit Care Nurs 2008; 2 4 :1 3 0 -1 3 6 7. Jasmine T: Art, science, or both? Keeping the care in nursing. Nurs Clin North Am 2009; 4 4 :415 -42 1 8. Morton PG, Fontaine DK: Critical Care Nursing: A Holistic Approach. Tenth Edition. Philadelphia, PA, Lippincott Williams and Wilkins, 2013 O ctober 2014 • Volume 42 • Number 10
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
