Stephanie Van Slyke

In this episode, Stephanie Van Slyke helps us to understand DNR orders and her success in helping clinical staff understand what they mean.

Transcript

0:00

Welcome to this episode of Bioethics for the People, the most popular podcast on the planet according to Grandma Nancy. I'm joined by my Co host Doctor Tyler Gibb, who if he weren't here recording right now, would probably be golfing. And I'm joined by my Co host Doctor Devin Stahl, who dutifully completes the same 5 New York Times puzzles every day.

0:28

All right, so Tyler, we have a fellow Michigander in the house. I prefer the term Michigan gangster. Oh well, that sounds like a bumper sticker but OK. Yeah, good friend of ours from up north as as we say here in Michigan, right.

0:44

So Stephanie is a clinical ethicist up north in one of the health systems around the very tip of the mitten, as we say.So, Stephanie, do you want to introduce yourself, please?Thanks, Ty.Good to see you both.And Devin.So yes, I am a nurse by practice, I guess, if that's what you want to call it.

1:02

But most of my nursing career has been in a hospital as an ICU nurse, which just kind of naturally drew me down the path of ethics because of a lot of the complexities that we find as an as an ICU nurse.And I've since kind of moved away from the bedside and now leader ethics consult service here at at the hospital.

1:21

A nurse ethicist?I'm trying to think I know a few, but it's actually not the more common path.It makes total sense to me that as a nurse at the bedside, you're seeing a lot of ethics issues and it would move you that way.And yet I haven't met a ton of clinical ethicists who also practice or at one point practiced as a nurse.

1:40

So you're this wonderful Unicorn in our space.Oh, thank you, Devin.I prefer gangster.Oh, right, right, right.Sorry.Come on, Devin, keep up.OK.So Stephanie, you're going to talk about a success story, right?

1:56

And so often in our world, we deal with the the difficult and the heavy and the dark kind of side of healthcare.But we wanted to highlight some things that have gone well or successes that people have had in their clinical ethics space.So tell us what you got from up north.

2:13

Thanks Ty.So this really stems from circumstances when I was still at the bedside.This goes way back to like 2014.I'll never forget this patient.I'll never forget this situation where the patient had ADNR order and I had interpreted it one way.

2:31

And come to find out there were other colleagues of mine who had interpreted what that meant differently.And she experienced a medical emergency and we didn't know what to do.We didn't know how to intervene.And it's kind of haunted me ever since that did I do the right thing?

2:49

Even though I called the provider and described what was going on, there wasn't a clear understanding of how far do we intervene and what does her do not resuscitate order mean.And so it really led me to ever since then dig deep into the literature that's out there.

3:08

And thankfully I found a whole bunch of it.But more importantly, just within my organization, we did just a survey of staff to say how do you interpret DNR?And at that time, what was interesting is we had a long list of options that people could choose from around code status, which I think was another complicating factor.

3:29

So we had a limited code option.We're essentially code status was presented to patients and families as a menu of options to choose from.Which isn't it?Which I don't think was really that uncommon during that time.

3:45

I think a lot of the other healthcare systems that I've worked with or worked for also had similar, like you said, a menu where it's, and let's talk through some of the options that somebody might have in this menu, right?So the obvious one is compressions for cardiac arrest, right?

4:01

Do you want that or do you not want that?So what are some other ones that people could choose?Yeah, whether or not you wanted to be intubated, whether or not you wanted a central line or transferred to a higher level of care, ours also included, do you want to be defibrillated?

4:16

Do you want to be given meds?You know, so this just madding, if you will, assortment of options for one particular procedure that really encompasses all of that.So it really put the nurses and staff in a tough position of, you know, what do I do and what don't I do?

4:36

It might be helpful to take like just one step back and say, OK, so ADNR order is a physician order.So it's not something that the patients elect outside of, you know, a situation in which the doctor orders this for them.But it's really if your heart stops, if you have a cardiac arrest, what do you want us to do?

4:54

Do you want us to let you die?You know, your heart stops, you are dead.Do you want us to try to revive you or do you not want that?And if you say yes, there's a whole lot of things that go into that because the protocol says that you have to.All those things you just named on that menu have to happen for a resuscitation attempt to be successful.

5:15

It's very unusual for CPR to work at all.Right.So do you know the current stats on in hospital cardiac resuscitation?Yeah, from some of the studies that I read for in hospital cardiac arrest, the success rates have been shown to be anywhere between 20 and 40%.

5:33

Outside of a hospital, it's much lower, 10 to 15%.But I think that the the key thing here is how do we define success?Is it merely just getting a heartbeat back?Because we know there are a lot of other kind of ailments that occur because of CPR itself.

5:52

And are, are those acceptable ways of living for some people, some of the conditions that they're that they're left in the loss of independence, so on and so forth.So you know, I think there's, there's a lot to be said about how do we define success?Because yes, if we're thinking about was CPR successful?

6:09

And if it did return a heartbeat, then yes, it was successful.But is that truly what we're looking for?Right.Most people will say it's only successful if, like, then they can get out of the hospital, right?They're not thinking I'm going to be intubated for the rest of my life.I might be unconscious for the rest of my life.

6:25

Those might be unacceptable successful outcomes.So even in that kind of small percentage, because you watch, you know, Grey's Anatomy and everybody just like gets resuscitated and they bounce out and they go, thank you so much.And they leave the hospital immediately.That doesn't happen.It's very violent.

6:40

We're breaking ribs often, So.And even then, even if success is only just getting it back, it's still pretty low.And as far as I know, if you don't do all the things that are required for cardiac resuscitation, there's no chance it works even getting your heartbeat back.

6:56

So you know, offering people like menu options doesn't make a lot of logical sense because it only works if you do all of it.Yeah, that certainly is the way that I approach it, much like you would a surgery, right?We're never going to offer somebody open heart surgery and then give them a list of options to choose from that are part of that surgical procedure, right?

7:17

It just, it's illogical and why CPR is kind of morphed into this menu of options is just fascinating to me.But the other piece I did want to add that that I think is a contributing factor to this.It's not only the list of menu options, but the wide range of code status options that I see among healthcare systems.

7:35

It's not all the same.So if a patient is taken care of in my health system, we have one particular policy that says these are your options.But if they go to a, a hospital, you know, downstate, it's very different.And so we're creating this confusion not only among the community, but also within our own profession of, of people really that should know what this means and should know how to intervene when somebody experiences cardiac arrest.

8:02

Something else I've seen in hospitals it worked in that creates confusion is some people think that if you're DNR, it means you don't want aggressive treatment in general, right?So if you're not willing to be resuscitated, if your heart stops, you're not willing to undergo other kinds of aggressive procedures.

8:18

And that is not true typically.So you can have in our hospital system somebody who says, OK, if my heart stops, that's the end of it.You can stop treating me.But until that time, I want you to try to do everything you can to keep me alive.It's just like, at that point, I want to stop.

8:35

If my heart stops, let it be stopped.But I want chemotherapy, and I want maybe to be ventilated or intubated if I need that.I might want all sorts of things unrelated to cardiac arrest, but that's my stopping point.Whereas other people might be at the point where they're saying I don't want anything aggressive.

8:51

I want to be able to die a natural death and CPR is not part of that.So make me DNR and make me what sometimes you call AND allow natural death versus others who might say I don't want you to try to restart my heart, but I do want everything else that you think might keep me alive, which we call COT or continue on treatment.

9:09

So we have to have a DNRCOT or a DNRAND, and all the folks at the bedside have to know the distinction between those two options.Yeah.And that's fascinating to hear you say that, Devin, because that that to me, I think is the problem that that we as a healthcare industry have not come to a place where we all define it the same.

9:32

And it's just creating mass chaos.And unfortunately, it's causing a lot of really difficult circumstances for our patients and their families.It seems to me that it's also creating this a scenario in which the burden of deciding what is a coherent medical treatment plan is put on the family or the patient.

9:52

Like how?How could anybody not with healthcare training understand the difference between the necessity for Defibrillation and pressors and like all these other things that are integrally entwined with each other and you can't, like you said, you can't stop 1 without the other.

10:08

But we're giving this family almost like it's their responsibility to tell us how to practice medical, Not us, but but tell the healthcare system how to practice medicine.Right.I and I wonder if it's a lot of that kind of massive pendulum shift that we've seen around patient autonomy, right?Super important that that's happened.

10:25

But to now kind of apply that same logic to code status and CPR administration, I think we've we've really messed that up as a profession.Yeah.So you saw this situation that's that's kind of stuck with you.

10:40

It's really common when we've been talking with individuals who have like a policy change that they've been in charge of or a Seminole case that's changed practice at their hospitals where it's something from a personal experience that really kind of gives them that motivation.So tell us what happened after this case.

10:57

So yeah, I really just did a lot of digging and a lot of just back finding.I was super curious, how did my, my, you know, my fellow ICU nurses interpret what DNR meant?How did some of my providers, our respiratory therapist, you know, a wide range of professions who, who come to a code, right?

11:16

And if you're not all on the same page, it can be quite messy.And So what we really dug into is first of all, our, what does our policy say?And is it clear?And we, we easily identified, wow, we have a lot of opportunity here to do some better work.

11:32

And of course, our Ethics Committee really dug into the policy.We're fortunate to have our palliative care medical director as our chair.And as you know, that profession usually does a good job of having these great conversations.So we really wanted to first start to look at when is code status really applicable, right?

11:53

Because we were worried we were seeing it used as more of a goals of care forum to kind of Devon's point where if somebody has ADNR order, somehow it's now kind of morphed into they can or can't have surgery that can or can't have chemotherapy.And that's, that's really not what code status does.

12:10

It tells us if you experienced cardiac arrest, do you want us to do CPR?So really simplifying that.But then we had to take it a step further because we do know there are those situations too, where someone may say, hey, if my heart stops, you know, let me go, let me just die a natural death.But what about severe respiratory failure?

12:28

And I think that's where a lot of the difficulty came with, well, do you have a DNRDNI or just a DNI or you know, and, and because of course this person still has a heartbeat it, but if we don't intervene when they're experiencing severe respiratory failure, it will eventually lead to no heartbeat.

12:47

So how do we do that?So we really started there like first of all, what does code status mean?And I think it's important to acknowledge too, the difference between code status and an out of hospital medical order, right, which commonly fall under the umbrella of advance directives.I know at my organization, we ran into some situations where if a person had checked the box no CPR in an advance directive, that was somehow interpreted as ADNR order for code status.

13:15

And so we had to dig into that as well to say code status is a little bit different.While it falls into the same vein of CPR, it's not applied in the same manner that an advanced directive is.So that's kind of where we started.And then once we, you know, narrow it down to it's really only applicable in these two clinical settings and that's it, period.

13:37

It doesn't impact whether or not somebody can have a surgical procedure, undergo chemotherapy, anything else.Really it's only two clinical scenarios, which is cardiac arrest and severe respiratory failure.And I think that helped a lot.I think 1 important thing for listeners to hear, I hear this all the time is that we, when we're talking about code status, patients will say, oh, I have that paperwork and you say, no, no, no, Code status is not your advance directive.

14:04

So you do not elect your own code status.It has to be a physician.And so if you don't want CPR, you have to tell your physician.So just for our broad listenership, please tell your physician if you don't want CPR because that will not necessarily follow from the paperwork that you filled out.

14:21

Great point of it.And I'd even add even if you're hospitalized, you say you don't want CPR and you do well and you go home and then you come back whether it's months or years later, you have to make the decision again every time It doesn't because you can change your mind, right?

14:37

And so just because you had ADNR one time doesn't mean that that's a forever thing.It's you get to choose every time and even as you, you know, go from, let's say the ICU to a step down unit again, you have to revisit, you know, are your have your goals changed?

14:55

And if you're in surgery, right, so we have this big problem at our hospital right now is that people say that they want to be DNR, but they want the surgery.And we know that if you're in surgery and your heart stops, it might be because of something the surgeons did in the process of that surgery.And it would be very easy for them to get your heartbeat back.

15:13

And that seems like a different scenario than having a spontaneous cardiac arrest.And so it's possible and actually preferable that if you're going to get surgery, you suspend the DNR just while you're in surgery and then it gets re enacted as soon as you leave the surgery.But that is also widely misunderstood amongst our clinicians as well as our patients.

15:34

Well, and I'd even argue that I don't think every patient should have to suspend their DNR for a surgical procedure.I really don't because if that's not in alignment with their goals, especially because we're seeing more and more palliative type surgeries, right?And if that person says, hey, if I die on the table, let me go.

15:52

But we're not finding many surgeons or anesthesiologists that are very comfortable with that concept.And so how can we ensure, again, patients have a right to participate in their treatment decisions and that includes whether or not they want to be resuscitated at all stages.

16:07

And if it is such a thing that the procedure is such a high risk that there is concern that this individual may experience cardiac arrest, for example, open heart surgery, that is a good example of a procedure where if the patient is very adamant that they wouldn't want to be resuscitated, they may not be a candidate for that procedure, period.

16:27

And are we, are we really kind of approaching those types of situations in that way?So what did you guys, what did you do with, with with this situation like so, so you, you, you did some review what is what is everybody think about this saw that your policy or maybe your documentation was at least contributing to the issues of misunderstanding.

16:49

And so where do you go from there?So what we did is we modified the options for code status.So we first we got rid of the limited code option.So what we narrowed it down to is the options include full code, which I think everybody understands what full code is.We also have the option of do not resuscitate.

17:06

And within our new policy, we specified how that is defined and what that means that in the event of cardiac arrest, so again the patient has lost their pulse, staff should not initiate CPR and instead allow the patient to die natural death.But if the patient were to experience severe respiratory failure, the patient still has a pulse and we would treat that patient, right.

17:27

So many times we hear DNR does not mean do not treat.And so if a patient has ADNR order and they experience severe respiratory failure, step should intervene, which includes endotracheal intubation with mechanical ventilation for those patients.

17:43

And then we also have 1/3 option of the DNRDNI.So do not resuscitate and also do not intubate.Now I think it's important to acknowledge though that that doesn't mean that somebody has a comfort care plan in place because that was another code status option that we had in our prior policy, which again that's a that's a goals of care, that's not a code status.

18:04

And so in my opinion, the three that we have now have have significantly clarified a lot of the confusion around that.So again, if a person has ADNR, DNI, cardiac arrest or respiratory failure, staff would not initiate CPR or endotracheal intubation, but of course, they could provide, you know, an escalation of therapies from a respiratory perspective.

18:26

So bi pap, you know, heated high flow, so on and so forth with the intention of prolonging life.But again, that's where those goals, those patient goals are going to be really important because a patient with a DNRDNI order could have a comfort care plan in place.

18:43

So we worked on a lot of education, patient identification, arm bands, patient alert signage outside of the doors so that staff knows kind of what the what the plan is.Because you know, in those situations you have to go act so fast and staff needs to know in what way they have to respond in those situations.

19:05

That's so interesting.We had in, I think this is all over Texas, banned the use of these arm bands because they were so often being interpreted as do not treat at all.And that they were like sort of signaling.People thought that if they had such a band, even if it only meant don't resuscitate my heart when it stops, that it also would mean that people wouldn't be as quick to treat them at all.

19:27

And so they've been totally banned.I think they're they're really wise.And it was just a response to like a practical like concern that patients were having about the use of that kind of signage.Well, and I and there's studies that show too patients that do have that DNR order are under treated.

19:43

And so I can certainly see why an organization would say, let's just get rid of the bans to maybe kind of mitigate any kind of risk for misunderstanding.But it doesn't address the underlying problem, right, that that there is a misunderstanding of what it means.And so our, our primary, primary focus was really to to provide the staff with this education to clarify and spell out what each code status option means and what the expectation is for them to respond in those situations.

20:14

What type of format did that education take?So in other episodes we've talked about sometimes the struggles that ethics education has and trying to find a foothold and trying to find timing, trying to find the right format to live deliver the information.So what was helpful for you guys?

20:30

So one, we have like an electronic, it's called health stream and electronic education, you know, platform that you create a PowerPoint, you assign it to people.But we knew that that wasn't going to be enough.And I have to tell you, I have to give a ton of credit to, like I said, the head of our Ethics Committee, Doctor Barraza, he and I really dedicated our time for about 3 months before the policy went live because this impacted more than one hospital in my healthcare system.

20:57

So this was multiple hospitals.So we knew this was going to be quite an endeavor.But we we really dedicated our time to have face to face meetings with staff.So staff meetings, we were invited to multiple meetings to meet with staff and allow them to ask questions.

21:17

We received a ton of questions, as you can imagine, on, well, what about the patient who wants CPR but doesn't want to be intubated?And so really helping to clarify the logic behind that and the reasoning for why it's, it would be unethical to do CPR without intubation.

21:33

And so we found that to be incredibly beneficial.And I will say what's interesting is this policy went live almost one year ago.So it was October 24th, 2023.So it's been a whole year.And the feedback that we have heard since then is how can we do that staff education like that for other things.

21:56

I just think you need that face to face opportunity to to bounce questions back and forth.You don't get that on electronic platforms or you know, little post, sign in post type, which is what we see a lot in healthcare, right print and post competencies and whatnot.

22:13

So I believe that that is what helped us to be as successful as we were in rolling out this new policy throughout our system.Do you think too, Stephanie, it helped that you are a nurse?I think sometimes the hardest communication is with the nursing staff, but the nurses are the ones that often have the confusion and are seeing kind of like things going down a path that could get to that point and are on alert and confused and raising this as an issue.

22:39

But the fact that you understand their concerns and their confusion, do you think that helped with the education?Yeah, I really think it it did.And I also think that having a physician, it was a physician and a nurse doing this education face to face, which was key in my opinion, because we were able to address the perspectives from both professions.

22:59

And so those physician nurse partnerships are so important.What type of questions or concerns did the folks at the bedside have when you were doing these educations?Well, there was a lot of argument about, well, if we don't allow patients options such as the limited code like we had forever, we are violating their autonomy.

23:21

And so really working through the logic behind that, just kind of the disconnect that that's not patient autonomy, that really CPR is an entire procedure and in order for it to be successful, you have to do everything that is part of that procedure.So really working on that.

23:38

Another thing that we heard a lot of at the bedside are those situations where a patient, and even if it's a patient who was receiving care downstate, now they're back home up here, they had the option to be a DNI only down there, it's not an option here.

23:55

And there was a lot of nurses that said, what do we say to patients who say I was ADNR at such and such hospital, Why can't I be 1 here?And there are those rare occasions I know even as I was an ICU nurse where you, you know, you can't feel a pulse.You jump on the chest and they push you off.

24:12

And you know, so sometimes again, in the heat of the moment, thinking that bag masking somebody only is just not, it's not logical to do that.You know, even if we get a pulse back to expect somebody to stand there and bag mask somebody to prolong their life, just, you know, trying to just really trying to help them think about it from a logical perspective versus an emotional 1.

24:42

And that's what I've seen a lot with the nursing staff, just that emotional connection to I need to do something and we're kind of telling them, well, but that is not something that is ethically permissible.Have you found that it's also helped just having the conversation?

24:57

I find that another issue that we have is nobody asked.And so the default is do everything and that might not be what the patient wants, but nobody had the conversation.And so we're just, you know, making everyone full code because we don't want to bother to have the the hard conversation.

25:14

Man, you know, if we could find out how often that actually happens, I think a lot of people make those assumptions, but it's difficult to know whether that's actually happening.You could certainly assume it is, especially if there's no supporting documentation of the discussion.

25:30

You just see that they're a full code or you see that they're ADNR or a DNRDNI.But you know, again, I think the discussions themselves, there's definitely an opportunity there around it.I know I've witnessed a lot of times where the even a nurse says ART, you know, when a patient says I want to be a full code, I want to be resuscitated and the nurse says, do you want us to jump on your chest and shove a tube down your throat?

25:53

Like that's that's not an informed decision, right?Like that's not how you have conversations about whether or not the patient is informed and able to make a decision based on what matters most to them.But that's how we see them.Right.And the way in which those discussions happen, I think show the the biases of what, what, what the provider wants the conclusion to be, right?

26:19

So I can describe chemotherapy in about 40 different ways, one of them being, you know, we're going to pump a bunch of poisons into your veins and hopefully kill only the the bad cells, right?And that's definitely persuasive in a certain direction, right?So if you, someone says, do you want us to jump on your chest and break your ribs and stick a tube down your throat, that's leading somebody to a certain conclusion where if you say, you know, do you want us to try to save your life?

26:43

You want us to, you know, a lot of other flowery ways of describing CPR in a in a way that also kind of shades the truth in a certain direction.Yeah, and I think even just the do you want us to save your life?I think is a little bit misleading as well because again, you know, so thinking, yeah, like I said, there's definitely some room for what what does it?

27:03

What should this conversation look like?Who should be having it?We, we received a lot of pushback from some of our providers who say, you know, I don't do code status conversations.And, and it just kind of, it kind of causes you to pause a little bit, you know, cuz in the hospital you have multiple subspecialties seeing a patient.

27:22

And so it was kind of being punted from one provider to the next and conducted in very different ways.And I don't think that that's unusual or only happening in my hospital.No, lots of providers don't like having the conversation.But to just sort of blanketly say, Oh no, I don't do that.

27:38

That's like, I don't have conversations about life and death with my patient who very well might die.Is a like absolutely outrageous thing to say.I had a provider once say that they are the ethics consultant on all of their patients and they don't need ethics to be involved because they are the ethical authority.

27:58

Oh, just.Be nice.One of my most favorite parts of being an ethics consultant is when you can get someone to like go have their aha moment.Like, oh, well, I hadn't thought of it that way.And I'm like, yes, let's think about it this way.Yeah.Do you have an example of that?

28:15

Honestly, a lot of it came through with the, the code status stuff, especially when I have, when I had staff who had, you know, strong convictions about why are we doing away with the limited code option And just literally the breaking it down too.

28:31

Let's think about what CPR is and what all goes into CPR in order for it to be successful.And it was just kind of, as we kind of, you know, peeled away the layers of the onion just kind of from a practical perspective, then I could see people come around.

28:48

Oh, I, you know, I haven't thought of it that way because I, because I've had some providers say, well, there, it's either life or death.And if I don't do CPR, they're going to be dead.And now I can't do anything.And it's like, well, but let's broaden that out a little bit more because I think you're right.

29:04

I think I think that's the message that's been out there as to why the community is really asked to learn to do CPR because it saves lives.And if I don't do this now, you know, somebody has died and and we have to acknowledge that cardiac arrest is a natural and expected part of the dying process.

29:21

Pretty much everyone's heart will stop at some point.Right, right.And there's this universal rule that you have to do CPR unless there's a DNR order.But yet the statistics don't support that.You know, it's always, the outcomes are always as good as we hope.

29:37

And so I just think there's a lot of room for us as a healthcare industry to really do something about this.After your policy change in the education, did you see any impact or hear any stories from patients about their, you know, improvement from their state of confusion or how it was helpful?

29:58

That's a great question.We really didn't do much inquiry into what from the patient's perspective or family perspective.We really just focused on staff, but I'd love to know whether it had a positive impact on patients, but we didn't really explore that.

30:17

So I've heard some people say sometimes we offer limited code because it is like a bridge to getting them to DNR, that maybe patients aren't just aren't quite or their families aren't quite willing to take that, that step.And so this is like one small way to get them, you know, toward.

30:35

And so eventually we want to get people toward DNR if they're on the path, but maybe they're not quite there yet.And so if the other option is full code, then if there's only these two star options that that doesn't get people moving.How do you what do you feel about those arguments?You know, and that's tough.I think in those situations, I worry that the healthcare professionals are taking on a decision making role that's not theirs to take, where they've made the decision.

30:59

This patient shouldn't be a full code for whatever reason.And again, we have to step back and remember what our role is in this equation.It's really to inform the patients, give them the information that they need to make an informed decision.And if it is such a thing that they're ponder, you know, we see patients go back and forth on a lot of things.

31:15

Whether or not they want to Trake and peg, whether or not they want to endure a particular surgery, we should be allowing them the time to think about those things and in the meantime, ensuring that they understand that if something were to happen, this is how we would respond.So we just want to make sure you're OK with that, but not necessarily trying to talk them into one way or the other.

31:38

And I see a tremendous amount of moral distress, a lot of times more so in nurses than providers who have those strong convictions about this patient should not be a full code.And I'll try to really like, well, tell me why, you know, tell me a little bit more about why you think they shouldn't be a full code.

31:56

I mean, based on the information about the wide range of misinterpretation that healthcare professionals have around what it means, I get why they all want to be full codes, right?So just helping them in ways to just inform the patients, empowering them to make decisions for themselves and try to let go of a feeling as though their bad decisions or decisions that we don't think they should be making are ours to somehow change.

32:26

So for our listeners who are, you know, in states all across the country and in different countries, how could they know what their local healthcare system or provider, how they approach code status, these types of questions?

32:42

That's a great question.You know, like I said, even in the state of Michigan, I see it, it's different at every health system.So to cross state lines, boy, I have no idea.I have no idea.That's that's why.

32:58

And I guess that's where I was getting at when I was talking about we as a healthcare industry, we owe more to our patients to get this right, to figure this out.The fact that we have such a range of misinterpretation and such a wide variation in code status options to me is problematic.

33:16

I mean, when you look at laws and, and you think of like out of hospital medical orders, like in Michigan, we have two, we have that, you know, do not Resuscitate Procedure Act and then we have our Michigan physicians in order for scope of treatment.It's pretty clear in the EMS protocols, you either do CPR or you don't, right?

33:32

And so why, why can't that also be applied in hospitals?You either do it or you don't, right?But we've really gotten, it's really gotten messy and I don't know how to fix it other than if anyone is going to try to fix it, it should be us, it should be the healthcare professionals, right?

33:51

This is such an interesting conundrum because usually what we're trying to do is add complexity and add nuance and trying to help people think deep differently and deeper.And whereas this issue is more like, no, it's either you do or you don't, right?It's either we're hitting the gas pedal or we're hitting the brakes, right?

34:08

It's kind of binary.So it's a little bit different type of motivation, but also different type of education and different type of problem solving that has to go into this type of issue.Well, and I, I can imagine there's several listeners out there who completely disagree with that thought process, right?

34:25

Who, who would to kind of your point, Devin earlier that it's, it's this gesture of I've done something, you know, for somebody or this, this feeling of it's a bridge to something else.But at the end of the day, are we doing a disservice to our patients by not being forthcoming with what CPR actually is, what it is intended to do, what it is, what all goes into CPR?

34:51

And I just wonder that if there's a better understanding both within the community, you know, they're not believing everything they see on television.But then even in the medical profession, is there a way to kind of close that gap a little bit?It might help too, if our providers knew more about or could explain better.

35:09

If you are DNR, that doesn't mean we're just going to leave you alone in your room and abandoned you.And, and part of it is that there are some providers who do feel that way, that oh, if, if their DNR, then they've given up.I've heard, I've heard actual physicians say that.And you're like, that's wild because there's so much comfort care that we can give to people.

35:27

There's still all sorts of care and treatment we give to people even when their DNR.And if we're not able to explain that, well, it might feel to the patient like, or their family like they're giving up.But we're not giving up on you.We just recognize that if you don't want us to jump on you and put a tube down your throat, or, you know, however more gentle you want to talk about it, we're not going to do things to hurt you, but we will continue to do things to help you.

35:51

Yeah, I love that.And I think that's I've also heard like loved ones say things similar to that, that gosh, if I, if I say yes, let's not resuscitate my loved one, I'm making the decision to kill them.When I hear that, it's very disheartening.

36:09

And again, it tells me we have really missed the boat here in the ways in which we're having conversations or the ways in which we're approaching CPR and DNR orders.I even remember during COVID I had so I even had a patient call me once and say, I want to talk to the, you know, ethics person because you didn't honor my wishes.

36:29

And I said, well, tell me, tell me about the situation.And she said, I had ADNR order and I had a heart attack and you took me to the Cath lab And I said, of course we're going to take you to the Cath lab.Your DNR order didn't even matter at that point.Like you had a heartbeat.We're going to treat you.You know, if you, you could have certainly said you didn't want to have or have your family members say you didn't want to go to the Cath lab.

36:50

But that's not ADNR order.Just so much misunderstanding around what that means.And I love your point, Devin, about just kind of softening that conversation a little bit more about there's so much we can do for people and it's not an all or nothing, right?

37:07

Which is sometimes how I've even heard CPR or code status conversations happen.Do you want us to do everything?And if they say no, it's well, now we're not going to do anything and just leave me in the room and let me die.And it's like, no, that is not what we're going to do or what it means.

37:24

Yeah, I know that a number of many, many institutions and people who work in clinical ethics have similar struggles with code status and the clarity of it and the process of it.And then once you have the process and the the policy kind of ironed out, doing the education is such a such a big lift, I think.

37:43

And so I think people are going to be really encouraged by your your success story.Thanks Ty.I really hope so and that, you know, that's that like I said, that's where we started with the policy and then we can continually refer people back to the policy when there's questions or concerns.

38:00

And so just having a well written policy I I think is key.I've read so many policies that I think, well, I don't even know what this thing is doing or saying.It's written by a lawyer, right?You're one of the good ones, right Ty?

38:18

Yeah, yeah.I'm one of the I, I think, so I don't know.Not a real lawyer, not a real doctor.Nothing's real.What a great place to end, Stephanie.This is so great and I think this will be really helpful to a lot of our listeners.

38:33

Thank you.I appreciate being here and I, you know, love sharing the story because it's something I'm incredibly passionate about and would love to see this get better on a larger scale.Thanks for tuning into this episode of Bioethics for the People.We can't do it alone, so a huge shout out to Christopher Wright for creating our theme music and to Darien Golden Stall for designing our logo and all of the artwork.

38:57

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