THESIS " M IGAN STATE UNIVERSITY us A Illllllllllllllll ll Ill Hulllll" 3 1293 01694 3593 This is to certify that the thesis entitled A DESCRIPTIVE STUDY OF THE PRACTICES SURROUNDING THE PATIENT SELF DETERMINATION ACT IN NURSING HOMES presented by Debra Zakrajsek has been accepted towards fulfillment of the requirements for M . S . degree in NursinL Major professor gas flea/w / Date 7424? N, /77/ 0-7639 MS U is an Affirmative Action/Equal Opportunity Institution LIBRARY Michigan State Unlverslty to remove this checkout fro TO AVOID PLACE IN RETURN BOX m your record. FINES return on or before date due. DATE DUE DATE DUE DATE DUE :. 6392604 1/“ WM“ A DESCRIPTIVE STUDY OF THE PRACTICES SURROUNDING THE PATIENT SELF DETERMINATION ACT IN NURSING HOMES By Debra Zakraj sek A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN NURSING College of Nursing 1998 ABSTRACT A DESCRIPTIVE STUDY OF THE PRACTICES SURROUNDING THE PATIENT SELF DETERMINATION ACT IN NURSING HOMES By Debra Zakraj sek The Patient Self Determination Act of 1990 (PSDA) requires health care facilities receiving Medicare funds to inform patients of written policy regarding the implementation of cardiopulmonary resuscitation (CPR), the patient’s right to declare an advance directive, and the patient’s right to declare a durable power of attorney for health care. Prior to the PSDA, few Skilled Nursing Facilities (SNFS) had either written policies or procedures addressing the use of CPR. The purpose of this study is to describe facility policy concerning the use of CPR, facility practices for eliciting and implementing advance directives, and facility capacity to provide basic life support. Using a random sample of SNFS in Michigan, this researcher found current SNF policy allows for professional judgement to override the patient’s choice in end of life decisions. In some cases, SNFS do not provide CPR as a treatment option regardless of advance directive status. In SNFS that do provide CPR as an option, less than half of those surveyed maintain adequate resources to perform CPR. Given the intent of the PSDA, the scope of nursing practice in SNFS is not being maximized. This study utilizes Orem’s model of Self Care Deficit Theory to explain the nurse’s role in eliciting, communicating, and implementing advance directives. Copyright by DEBRA ANN ZAKRAJSEK 1998 TABLE OF CONTENTS LIST OF TABLES ................................................ vi Chapter 1 -‘ INTRODUCTION ........................................ 1 Purpose .............................................. 5 Summary ............................................ 5 Chapter 2 - CONCEPTUAL FRAMEWORK ............................ 7 Orem's Self Care Deficit Theory .......................... 8 Orem's Theory of Nursing System ......................... 9 Application of Orem's Nursing System Theory .............. 10 Summary ........................................... 12 Chapter 3 - REVIEW OF RELEVANT LITERATURE ................... 14 Eliciting Advance Directives ............................ 14 Written Policy Regarding CPR .......................... 16 Procedures Regarding CPR ............................. 19 Summary ........................................... 20 Chapter 4 - RESEARCH METHODOLOGY ........................... 21 Operational Definitions ................................ 22 Instrument .......................................... 24 Protection of Human Subjects ........................... 25 Chapter 5 - RESULTS ............................................. 26 Eliciting Advance Directives ............................ 26 Reviewing the Advance Directive ........................ 27 Documenting the Advance Directive ...................... 28 Implementing Advance Directives ........................ 30 Capacity for Providing CPR ............................ 31 Chapter 6 - DISCUSSION .......................................... 32 Summary of Findings .................................. 33 Limitations of the Present Study ......................... 35 Implications for Practice ............................... 36 The Need for Future Research ........................... 37 REFERENCES .................................................. 39 iv APPENDICES ................................................... 43 APPENDIX A ............................................. 44 Data Collection Tool .................................. 45 APPENDD( B ............................................. 49 Cover Letter for Survey ................................ 50 APPENDIX C ............................................. 51 Cover Letter for Second Mailing ......................... 52 APPENDIX D ............................................. 53 Protection of Human Subjects ........................... 54 LIST OF TABLES TABLE 1. Frequency of Routine Advance Directive Reviews .................... 27 TABLE 2. Significant Change of Condition Prompted Advance Directive Review . . . . 28 TABLE 3. Chart Placement of the Advance Directive .......................... 29 TABLE 4. Documentation of Advance Directive in Addition to the Medical Record . . 29 TABLE 5. Facility Practice Concerning the Use of Professional Judgment to Withhold CPR ........................................................ 30 vi Chapter 1 INTRODUCTION Since the advent of cardiopulmonary resuscitation (CPR), weighing the benefits for the use of CPR against the costs of withholding CPR has been both an ethical and moral dilemma, especially concerning geriatric clientele. CPR was developed in the 19605 for select cardiac and surgical patients (DeBard, 1980). Thereafter, a national campaign soon promoted teaching CPR to health care professionals, as well as lay people. As a result, CPR became standard operating procedure for all patients experiencing respiratory or cardiac arrest. The generalized use of CPR has been criticized from several perspectives including benefit cost analysis (Gillick, 1988; Applebaum, King, & Finucane, 1990; Hanson & Danis, 1991), risk benefit ratio, (Awoke, Mouton, & Parrott, 1992) and quality of life for survivors (Braithwaite & Thomasma, 1986; Tresch, 1991). Several researchers have noted a relationship between advancing age and poor outcome for CPR (Applebaum, King, & Finucane, 1990; Awoke, Mouton, & Parrott, 1992; Hanson & Danis, 1991). Annually, 6% of all Medicare recipients die, accounting for 27.9% of the total expenditure of Medicare benefits (Gillick, 1988). Considering low survivorship, poor outcomes, and exorbitant costs, Gillick and others propose denying CPR to Medicare recipients as a cost containment measure (Callahan, 1989; Hanson & Danis, 1991). On the other hand, Tresch (1991) proposes that some elders demonstrate good outcomes after receiving life-saving CPR. These patients typically have access to immediate emergency care, are in good health, have few chronic diseases, experience chest pain and dyspnea, and present with ventricular fibrillation or ventricular tachycardia at the time of the arrest. Given that a subpopulation of elders exhibit good outcomes, Tresch contends multiple pathology, rather than age, is the decisive factor in the successful use of CPR. Tresch’s perspective considers the risk benefit ratio of the individual rather than chronologic age as the predicting factor for successful outcomes when implementing CPR in the elderly. As post-CPR outcomes are difficult to predict, Braithwaite and Thomasma (1986) suggest quality of life rather than age as the criterion for determining the risk benefit ratio. Given that quality of life is subjective, the patient must be consulted regarding his perception of what an acceptable level of quality of life is before the decision to withhold or implement CPR is made. Knowing there is a functional decline post-CPR, the patient needs to decide at what point CPR would no longer be an acceptable treatment option for himself or herself. While much has been written about the patient’s autonomy to express his or her right to death with dignity through the use of medical advance directives; to date, little research is found in the literature which evaluates the patient’s right to life, including access to care (i.e., CPR) in the event of cardiac arrest or respiratory arrest. Prior to the PSDA, most nursing homes did not have written policies or procedures regarding the use of CPR (Lipsky, Hickey, & Browning, 1989; Miles & Ryden, 1985; Levinson, Shepard, Dunn, & Parker, 1987). The majority of nursing homes did not even attempt to provide CPR (Duthie, Mark, Tresch, Rartes, Nearhring, & Aufderheide, 1993; Finucane, et. al., 1991). For professional clarity, in 1986 the American Medical Association Council on Ethical and Judicial Affairs recommended that end of life decisions be made in collaboration with the patient (or the family in the case of an incompetent patient). The council said CPR could be withheld if the patient has a medical advance directive (either a living will or proxy decision maker) or when CPR is medically futile. Medical futility is defined as the presence of any of the following: a malignant disease process, neurological disease process, renal failure, respiratory failure, sepsis, or multi-organ failure. The council declares professional judgement may be used to withhold CPR in the event of decapitation, rigor mortis, tissue decomposition, or extreme dependent lividity. However, when the decision is made to carry out CPR, it should be carried out skillfully and without hesitancy. In 1986, the National Conference of Standards for CPR and Emergency Cardiac Care, sponsored by the American Heart Association and in conjunction with the National Academy of Science-National Research Council, outlined the minimum patient care standards for providing CPR (1986). The council suggests certification in CPR (basic life support) be a mandatory professional standard was well as a pre-employment requisite which must be maintained, thereby making CPR immediately available in primary, secondary, and tertiary care settings. Additionally, supplemental services should be provided by trained staff as soon as possible following the initiation of basic life support and adjunctive therapy including oxygenation, ventilation, and airway control (J AMA, 1986; Payne, 1986; Wynne, 1990). To maintain ventilation, the use of a bag-valve device and oralpharyngeal airway is suggested when trained staff is available. Suction V equipment with a minimum airflow of more than 30 liters per minute as well as a vacuum of more than 300mm of Mercury should be available. To ensure adequate circulation, a bed board extending the distance from the victim’s shoulders to waist and across the full width of the bed should be accessible. The initiation of a reliable intravenous route should be established early, as the need to expand circulating blood volume as well as to keep lines open for later drug administration is crucial. The quick stabilization of the victim increases the effectiveness of emergency personnel. This means the victim receives effective ventilation and circulation as well as a functional intravenous line at the scene. The Council goes on to suggest advance cardiac life saving capability needs to be either immediately available or within ten minutes response time from facilities where large captive audiences are present. These position papers cited are the most recent published. In 1992, both the American Red Cross and American Heart Association changed the method of implementing CPR (i.e., the rate of chest compressions per minute, the rate of chest compressions to ventilation, and method of opening airway for artificial ventilation); however, no change was adopted in defining adequate resources for providing basic life support. While the intent of the PSDA is to provide the patient with the means to express end of life decisions, the focus has been on the individual’s right to death with little consideration for the individual’s right to life through access to quality care (i.e., CPR). To date no research describes current policy or procedures concerning the implementation of advance directives in SNFS. Purpose The purpose of this study is to describe current facility policy concerning the use Of CPR, facility practices for eliciting and implementing advance directives, and facility capacity to provide basic life support. Using a random sample of SNFS in Michigan the present study describes the current policy and procedures. This study will specifically address practices for eliciting advance directives, policy concerning the use of CPR, and facility capacity to provide basic life support. By surveying a random sample of SNFS in Michigan, the present study focused on answering the following research questions: 1) Who is responsible for patient education about declaring an advance directive?; 2) How often is the advance directive reviewed with the patient and by whom?; 3) Do all SNFS Offer CPR?; 4) How many SNFS utilize professional judgement as a means of withholding CPR?; and, 5) DO SNFS have adequate resources to provide basic life support as defined by the minimum patient care standards for providing CPR per the American Heart Association and the National Academy of Science-National Research Council? Summary The advent of CPR was designated for select cardiac and surgical patients (DeBard, 1980). AS public awareness increased, through programs which trained lay people in the practice of CPR, CPR became standard operating procedure for all patients experiencing respiratory or cardiac arrest. Over time this generalized use of CPR was criticized on the basis of benefit cost analysis (Gillick, 1988; Applebaum, King, & Finucane, 1990; Hanson & Danis 1991), risk benefit ratio (Awoke, Mouton, & Parrott, 1992), and quality of life for survivors (Braithwaite & Thomasma, 1986), and the right to death with dignity. Subsequently, the PSDA intended to mediate the issue by giving the patient autonomy to maintain control over himself or herself, regardless of functional capacity, through the use of an advance directive or durable power of attorney for health care (DPOAHC). It is known that prior to the PSDA, most nursing homes did not have written policies or procedures regarding the use of CPR (Lipsky, Hickey, & Browning, 1989; Miles & Ryden, 1985; Levinson, Shepard, Dunn & Parker, 1987). The majority of nursing homes did not even provide CPR (Duthie, Mark, Tresch, Rartes, Nearhring, & Aufderheide, 1993; Finucane, et. al., 1991). Given the focus of attention has shifted from paternalistic care towards the individual’s right to self determination, it is surprising to find little research describing what interpersonal processes occur when declaring an advance directive. In particular the role of the nurse-patient relationship has not been examined. The gerontological advance practice nurse (APN) (either as a Clinical Nurse Specialist or Nurse Practitioner) has not been active in reporting data concerning the elicitation and implementation of advance directives from a population management perspective. In part, this may be due to the fact that few gerontological APNS are employed by skilled nursing facilities and the population of skilled nursing facilities is under represented in nursing research. This pilot project is limited to describing current practices in skilled nursing facilities used to elicit and implement advance directives. Using Orem’s Self Care Deficit Theory, chapter two suggests several options for future research which would examine specific roles the gerontological APN uses to elicit and implement advance directives. Chapter 2 CONCEPTUAL FRAMEWORK Nursing home care is transforming from a paternalistic medical model to a client-centered collaborative approach. Today it is commonplace for nursing home care to reflect mutual goal setting, focus on maximizing independence in activities of daily living, and provide surrogate care consistent with past life choices of the individual. This shift from paternalistic care to client-centered care is due in part to the Ombudsman Reconciliation Act of 1987. This legislation is best remembered for defining and limiting the use of physical and chemical restraints. Perhaps more importantly, it shaped the philosophy of collaboration as the cornerstone of client-centered care. The PSDA of 1990 continues the reformation of nursing home care by empowering the client to maintain control over himself or herself, regardless of functional capacity, through the use of an advance directive or durable power of attorney for health care (DPOAHC). The PSDA implicitly assumes that people are capable and willing to make choices regarding their own health care outcomes and that a designated other (DPOAHC) is able and willing to deliberately and systematically carry out these decision making activities on another’s behalf. These implicit assumptions are the foundation of Dorothea Orem’s Self Care Deficit Theory (Meleis, 1991). Orem’s Self Care Deficit Theory also assumes that people desire the power to govern choices and are able to make conscious decisions regarding health care options, which will promote or maintain a state of health acceptable to each individual’s desired quality of life. Orem also assumes that each individual has a social tie with another person who is willing to assume such decision-making processes if so needed. Both the PSDA and Self Care Deficit Theory focus on client centered care and the use of a proxy (i.e., DPOAHC and proxy care giver/nurse agent respectively) when the individual can not function on his own behalf. Orem’s Self Care Deficit Theory serves as the conceptual framework from which the researcher studied current policy and procedures related to advance directives. Of specific importance to the present study, Orem defines two separate but related theories: a theory of Self Care Deficit and a theory of Nursing Systems (Orem, 1985). This chapter presents an overview of these two theories, pertinent concepts, and application as related to PSDA. Orem’s Self Care Deficit Theory Orem’s theory is categorized as a self care needs theory. It is grounded in recognizing that each individual must overcome or satisfy universal physiological, developmental, and health deviation requisites, in order to achieve health and well-being. Orem distinguishes between health, as structural and functional integrity of the physical self, and well-being, which is the experience of self-acceptance and movement towards the perceived ideal self (Orem, 1991). Within each individual lies a power component (i.e., cognitive, psychomotor, and affective Skills) which promote one’s self-efficacy in managing and meeting health care needs (Orem, 1987). The focus of nursing care (nursing therapeutics) is to empower growth and development of each individual’s state of health and well being. This interactive nurse-client relationship is defined with Orem’s second theory, the Theory of Nursing System. Orem’s Theory of Nursing System Orem describes nursing as an art, a science, and a human service. Nursing is the deliberate and unique action of assessment, diagnosis, prescription, and planning within social roles, interpersonal relationships, and technical components of health care. The goal of nursing is to promote or restore health and well-being by empowering the patient to accomplish self care or to facilitate a significant other in the surrogate role of self care agent (proxy care giver) within the agreed plan of care. Orem proposes nursing care is relative to time. That is, across time the individual’s ability to participate in self care activities, the amount of support from the care giver (self care agent), and the amount of involvement by the nurse changes to meet self care demands. The degree of support required varies with the intensity of demand and power capacity component of the individual or self care agent (Orem, 1985). Orem clarifies this phenomenon through the identification Of three separate nursing care systems. Orem describes the individual’s degree of self care capacity and the degree of support provided by a nurse or proxy care giver in one of three modes (i.e., Supportive-Educative, Partially Compensatory, and Wholly Compensatory). The individual who is independent with self care requires nursing care that only assesses health and provides health promotion information (Supportive-Educative System). Orem uses the name Partially Compensatory System to describe the individual who requires assistance from the nurse or proxy care giver to perform part of the activities Of daily living. Lastly, Orem presents the Wholly Compensatory System. In this mode the functional level of the individual is dependent on the nurse or care giver (Orem, 1987). The individual’s capacity to make modified-independent decisions is gone. In this system the nurse accomplishes the patient’s therapeutic care needs, compensates for individual’s loss of physical function, and supports/protects ego integrity by providing care consistent with patient’s past preferences. The practice of eliciting and implementing advance directives can be guided through the application of Orem’s theory. Both the nursing roles and the use of advance directives can be depicted using Orem’s Nursing System Theory. The application of Orem’s theory to predict the nursing role characteristics and use of advance directives is outlined below. Application of Orem’s Nursing System Theory In the Supportive Educative mode, the role of nursing practice focuses on health promotion needs and educational needs of the individual related to current health status and well being. The nurse collaborates with the patient to identify current status of health, desired state of health, the predicted optimum level of health, and strategies to maintain and/or reach desired state of Optimum health and well being. In this mode the nurse may use any or all of the following nursing roles: assessor, change agent, client advocate, clinician, consultant, counselor, educator, evaluator, leader, and planner. The focus of nursing is to provide information and facilitate the client’s continued independent/modified independent functional level to reach a satisfactory quality of life. In this mode, the nurse informs the client of the right to declare an advance directive and DPOAHC. The nurse facilitates client action to examine individual value system and care choices which are consistent with the client’s desired quality of life. When the client has declined to the point of needing physical support in some areas of functional activities of daily living (Partially Compensatory System), either the 10 nurse or the care giver compensates for the client’s deficit by meeting the self care deficit demand on behalf of the individual. The client is still able to participate in care; however, participation is limited. The client presents as one who needs limited or extensive assistance in performing cognitive or physical acts of activities of daily living. In this system, the nurse continues to function within the same roles as in the supportive educative system; but expands nursing practice to include the roles of coordinator, evaluator, and educator for care giver training. Similarly, the DPOAHC has a greater role in meeting self care demands; however, this relationship is indirectly proportionate to the functional decline of the individual. In this mode, the client is still capable of initiating or changing an advance directive or declaring a DPOAHC. Using the same techniques, the nurse will facilitate the development and/or implementation of the patient request for an advance directive and DPOAHC. However, if cognitive impairment is present it is wise to validate the expressed choice on more than one interaction. In the Wholly Compensatory Nursing System, the client demonstrates complete dependence on either the proxy care giver or nurse. The physical or cognitive demands of activities of daily living can no longer be met by the combined efforts of the individual and the DPOAHC. In this system, the nurse provides for all activities of daily living consistent with past individual preferences as well as any treatment requests or limitations stated in an advance directive. The nurse collaborates with the DPOAHC to insure the revised plan of care is congruent with past patient desires. Nursing practice includes the nursing role characteristics previously presented. The nurse emphasizes the roles of client advocate, clinician, coordinator, and evaluator. ll In this system, the nurse moves from a collaborative relationship with the DPOAHC to a consulting relationship with the DPOAHC. That is, the nurse confers with the DPOAHC for treatment choices; but since it is the nurse agent who delivers the care, the nurse assumes sole responsibility for patient outcomes related to care delivered. Hence, professional judgment may be utilized, as in the case of medical futility, to withhold CPR. Summary The PSDA of 1990 empowers the client to maintain control over himself or herself, regardless of functional capacity, through the use of an advance directive or durable power of attorney for health care (DPOAHC). As previously stated, this legislation implicitly assumes that people are capable and willing to make choices regarding their own health care outcomes and that a designated other (DPOAHC) is also able and willing to deliberately and systematically carry out these decision making activities on another’s behalf. These implicit assumptions are the foundation of Dorothea Orem’s Self Care Deficit Theory. These assumptions parallel Orem’s theory of nursing system, in that the individual has the capacity and ability to make decisions about how to meet the Universal Self Care Demands for the purpose of growth and development. As the person’s ability to meet his or her self care demands decreases, Orem assumes that the individual has another significant other (i.e., self care agent/proxy care giver) who is able and willing to assist in meeting these demands (e. g., Partially Compensatory System). Orem further proposes the proxy care giver or nurse will meet the self care requisites for the individual who is totally dependent (i.e., Wholly Compensatory System). Orem theorizes that the role of the nurse 12 becomes more involved as the individual’s ability to meet self care demands moves from a state of independence to dependence (Orem; 1987). Before the nurse-patient relationship can be studied using this conceptual model, basic research is needed which describes current policy and practices addressing the implementation of the PSDA. Knowing the work culture related to policy and procedure concerning advance directives in SNFS is necessary to understanding the role nursing plays in the elicitation and implementation of advance directives. The purpose of this study is to describe facility policy concerning the use of CPR, facility practices for eliciting and implementing advance directives, and facility capacity to provide basic life support. After this information is known, future research can examine the nurse patient role-interaction in the various nursing system modes. l3 Chapter 3 REVIEW OF RELEVANT LITERATURE The goal of the PSDA is to guarantee each person the control and possession of himself without interference from others when making life and death decisions about health care (White & Fletcher, 1991). PSDA requires health care facilities receiving federal funding inform patients of written policy regarding the implementation of CPR, the patient’s right to declare an advance directive, and the patient’s right to declare a DPOAHC. Research prior to this legislation suggests few nursing homes had written policies or procedures regarding the use of CPR (Lipsky, Hickey, & Browning, 1989; Miles & Ryden, 1985). Rarely was patient participation in end of life decisions studied. Since the passage of the PSDA, some researchers have questioned how advance directives are elicited and selected by nursing home residents (Bachelor, et. al., 1992; Schoonwetter, et. al., 1991 ). Eliciting Advance Directives Bachelor, Winsemius, O’Connor, and Wetle (1992) evaluated the effectiveness of an advance directive policy at a large Jewish affiliated nursing home in the eastern United States. They sought to determine the factors influencing the decision to refuse CPR and the amount of time that passed before documentation was completed. The authors noted the following factors increased the likelihood the patient would refuse CPR: having a primary physician who was employed by the nursing home, the patient demonstrates decreased cognitive or physical function, the patient is of advanced age, or if the patient identified a proxy decision maker. They suggest surrogate decision makers choose 14 restrictive care choices because the patient’s decline in cognitive ability is seen as a decrease in quality of life. An admission nurse clinician was responsible for educating the patient and family regarding advance directives within 30 days of admission. If the patient seemed incapable of making the decision, the nurse collaborated with the family to Obtain the resident’s assumed preference. Interestingly, most conversations about advance directives were initiated by the families or patients with the nurse rather than the primary physician or social worker. Prior to the initiation of the advance directive policy, the median time delay for documenting a code status was 54 days. After implementing the advance directive policy, the median time for recording an advance directive status was one day post admission. Numerous editorials (Annis, 1991; Council on Ethical and Judicial Affairs, 1991; Ebell & Eaton, 1992; Emanuel, 1991; Madson, 1993; White and Fletcher, 1991; Youngner 1987) and the research mentioned above leads practitioners to believe that declaring a medical advance directive is an ongoing educational process rather than a behavior that fulfills federal legislation. The primary care provider is responsible for continuously evaluating the patient’s health status and potential outcome for CPR (Emanuel, 1991). The editorials by experts identified above concur that when a person’s health deteriorates without likelihood of reversing to an acceptable quality of life, it is time to implement a medical advance directive. As most nursing home residents exhibit functional decline, the request for CPR would most likely be low, as compared to the general population. In actuality, according to the available literature, the incidence of CPR in nursing homes is rare. 15 Written Policy Regarding CPR At a time when using CPR was Standard operating procedure for any individual experiencing cardiac or respiratory arrest, Miles and Ryden (1985) investigated the practice of withholding CPR in nursing homes. Using a random sample, they surveyed 135 of the 441 licensed nursing homes in Minnesota to determine if physician orders to limit the treatment of residents were used and if this practice was formalized in a written policy. A majority (73%) of nursing home administrators acknowledged the use of withholding CPR in some cases, particularly in homes that had ethics committees, student teaching programs, or a religious affiliation. In such homes, the focus Of nursing care was to promote death with dignity through comfort measures, hygiene, and supporting family involvement. Even though most facilities focused on comfort care (77%), relatively few (16.3%) of these homes had written policies and protocols for palliative care measures when patients were terminally ill, suffered severe physical or cognitive dysfunction, had a deteriorating medical condition, or were unresponsive to therapeutic or rehabilitative intervention. More than half of the homes with written protocols required assistance in planning palliative care interventions from social workers, clergy, director of nursing, the administrator, or an ethics committee. In a similar survey, Lipsky, Hickey, and Browning ( 1989) noted that three-fourths of the nursing homes in northwest Ohio accepted orders from physicians to withhold CPR as long as the family or patient voiced agreement to withhold CPR. Analysis of nursing home characteristics found a direct relationship between the practice of withholding CPR and Medicare certification. This may well be due to Medicare certification requiring skilled nursing care, meaning that these homes are more likely to see a sicker, frailer l6 clientele who demonstrate lower functional levels. Yet, some SNFS do offer CPR as a treatment Option (Finucane & Denman, 1991; Duthie, Mark, Tresch, Rartes, Nearhring, & Aufderheide, 1993). Using a convenience sample of 58 nursing home administrators, medical directors and nursing directors, Finucane, et. a1. (1991) assessed the incidence of CPR in various regions across the United States. Over a 2 year period, CPR was never attempted in 33 of the 58 (57%) nursing homes. Seven of the 58 nursing homes implemented CPR twice, and 2 of the 58 nursing homes performed CPR three times in one year. One home each reported implementing CPR 4, 5, 6, 8, 11, 12, 19, 20, and 30 times in one year. Although most nursing homes did not implement CPR, those which did implement CPR had a nursing staff which was required to maintain CPR certification. The researchers did not find religious and academic affiliation, propriety status, and size significantly associated with the use of CPR. Finucane and Denman (1991) believe the incidence of CPR in nursing homes is unusually low, given the reported number of deaths, and questions whether the administration of CPR in nursing homes is under reported or if CPR is under used? In response to this question, Duthie, Mark, Tresch, Kartes, Nearhring and Aufderheide (1993) carried out a retrospective survey of nursing home residents who received CPR. Every nursing home (N=68) in Milwaukee, Wisconsin was represented in the study. The researchers used a computerized register of paramedic runs providing CPR to nursing home residents over 4 years (1986-1989). During this time, paramedics performed CPR on 196 nursing home residents from the 68 nursing homes in Milwaukee. By comparing the ratio of CPR attempts to deaths occurring within a nursing home, the 17 researchers established the rate of occurrence of CPR. Duthie, et. al., report a rate of 0.02 CPR to death ratio. The ratio remained consistent across the 4 years; however, variability between nursing homes existed. The authors reported that 53% of the non-profit homes had no residents receive CPR (CPR: death ratio=0.011), compared to proprietary homes, in which 29% had no residents receive CPR (CPR: death ratio=0.027; P<0.05). This study suggests CPR is not influenced by size of nursing home, although it appears that non-profit homes use CPR less frequently than proprietary facilities. Facilities with greater numbers of deaths per bed capacity reportedly use CPR less often. Duthie, et. al., (1993) suggest that the costs Of maintaining certification in CPR, as well as the necessary equipment, may deter non-profit homes from offering CPR. Another explanation offered considers that the mission of a nursing home may contradict the use of CPR. Thus, facilities which have more deaths per bed may offer CPR less often because death is an expected outcome of Old age. Research conducted before implementation of the PSDA focused on facility policy to withhold CPR; the patient’s choice to refuse treatment was not addressed (Miles & Ryden, 1985; Lipsky, Hickey, & Browning, 1989). Historically, SNF care was paternalistic rather than collaborative. The patient choice to limit or refuse treatment in end of life decisions was not a social concern. Therefore, it is unknown to what degree the patient made an informed decision to have treatment withheld or refused treatment. Today, the PSDA enforces collaboration through informed decision-making and informed proxy decision-making regarding life and death decisions in health care. To date, there remains little research reflecting how long-term care facilities elicit patient’s decisions requesting or refusing CPR and the ability of the facility to provide CPR. 18 Procedures Regarding CPR Questions concerning the procedure for implementation of advance directives remain unaddressed. TO date, only one study has examined both the presence of nursing home policy regarding emergency cardiac and respiratory care and the ability of the facility to provide adequate emergency cardiac or respiratory care (Levinson, Shepard, Dunn, & Parker, 1987). Directors of nursing, medical directors, and administrators of long-term care facilities in Portland, Oregon (N=75) were surveyed for the presence of written policy and adequate supplies to provide CPR. Seventy-six percent of the nursing homes surveyed responded. As this study occurred before the PSDA, only 41% of the respondents reported having a written policy. Common practice for withholding CPR from a resident required a written physician order in 82% of the homes. Of those homes with a written policy regarding using and withholding CPR, patient preference for or against the use Of CPR was elicited routinely only 43% of the time. The use of institutional policy regarding resuscitation was inconsistent. Orders to withhold CPR were written and recorded in the majority (82%) of homes; homes without a written policy (46%) documenting wishes to have CPR administered or withheld reportedly withheld CPR in the event of death. Fifty-eight percent of these homes report various degree of readiness to provide emergency care. The majority of the facilities required certification in CPR as a pre-employment requirement for registered nurses (66%), for licensed practical nurses (65%), and for nursing assistants (52%); however, only 54% of these homes had a recertification policy. Thirty percent of the homes had an "emergency", and one-half of facilities had resuscitation equipment available. Most had supplemental oxygen (85%), suction 19 equipment (82%), hand held ventilation equipment (58%), and intravenous therapy and intravenous medication (52%). Three percent of the facilities had the ability to use endotracheal tubes and one-half of one percent of the facilities had electrocardiogram machines. None Of the facilities had defibrillators. Overall, half of the nursing homes were relatively well prepared to provide emergency services when indicated by physician order. Summary Prior to the PSDA, most nursing homes lacked formal policy regarding the use of CPR (Levinson, et. al., 1987; Lipsky, Hickey, & Browning, 1989; Miles & Ryden, 1989). Those nursing homes that had written policies regarding the use of CPR lacked adequate resources to provide CPR (Levinson, et. al., 1987). It may be that CPR is underutilized in long term care due to facility mission statements, proprietary status, or patient acuity (Miles & Ryden, 1985; Lipsky, Hickey & Browning, 1989; Finucane & Denman, 1991). The PSDA mandates that nursing homes receiving federal funding inform patients of written policy regarding the use of CPR, the patient’s right to declare an advance directive, and the patient’s right to declare a DPOAHC. However, the legislation does not require that nursing homes maintain adequate resources for providing CPR according to the standards of practice. The purpose of this study is to describe current SNF capacity, policy and practices surrounding the use of advance directives and CPR. This study will Specifically address practices for eliciting advance directives, policy concerning the use of CPR, and facility capacity to provide basic life support. 20 Chapter 4 RESEARCH METHODOLOGY This descriptive study examines current policies and procedures for implementing the PSDA in selected Skilled nursing facilities in Michigan. The research questions assessing how advance directives are elicited, reviewed, and implemented are listed below: 1) 2) 3) 4) 5) 6) 7) 8) 9) In relation to nursing home placement, how soon are residents informed of their right to declare an advance directive and DPOAHC? Which discipline informs residents of the right to declare an advance directive? What percent of the facilities have formal Ethics Committee to assist families and staff with end of life decisions? What percent of the facilities require a physician order to initiate a "no code" status for the residence? Where are requests to limit treatments recorded? How frequently are advance directives (code status) reviewed after admission to the facility ? What percent Of the skilled nursing homes offer CPR? What percent of the skilled nursing homes are adequately prepared to provide CPR? Is professional judgement/medical futility used to withhold CPR? 21 Operational Definitions For clarity the researcher has identified concepts critical to this study and presents the following Operational definitions for each concept in this study. Skilled Nursing Care Facility (SNF). A nursing home is defined in Act 368, Public Acts of 1978, as a nursing care facility other than a hospital long-term care unit or county medical care facility that provides nursing care and medical treatment to 7 or more unrelated individuals suffering or recovering from illness, injury or infirmity. More specifically, a nursing home that employs a Registered Nurse for eight continuous hours per day (on the premises) and has 24 hour access to a registered nurse (on call) is considered able to provide skilled nursing which qualifies the facility for Medicare reimbursement for skilled care provided. Resident. A resident is recognized as an individual receiving in house nursing and medical care from a SNF. This term is interchangeable with patient and client. Advance Directive. A written document stating a patient’s preference regarding life supporting and life sustaining treatment choices which goes in effect when the individual is no longer competent to express such choices. Durable Power of Attorney for Health Care (DPOAHC). The DPOAHC is a proxy decision maker preselected by the individual. The DPOAHC, identified in writing, is given the power to consent to or refuse medical treatment on the behalf of the individual who is unable to participate in such decisions (Living Wills and Durable Power of Attorney for Health Care, 1991). Cardiopulmonary Resuscitation. Cardiopulmonary resuscitation (CPR) is synonymous with Basic Life Support for the professional by both the American Heart 22 Association and American Red Cross. It includes artificial respirations (i.e., mouth- to-mouth, mouth-to-stoma, or the use of an arnbubag to mouth or stoma) and artificial circulation per closed chest compressions. Adequate CPR Resources. In 1985, the National Conference of Standards for CPR and Emergency Cardiac Care along with the National Academy of Science-National Research Council developed a position paper establishing the following criteria for minimally acceptable resources for the provision of CPR: the presence of staff certified in CPR, a back board, an ambubag with supplemental oxygen (100% flow rate), and a suction machine (300mm Hg suction). Medical Futility (i.e., professional judgement). Guideline to make a unilateral decision to withhold CPR due to the presence of the following: a malignant disease, neurological disease, renal failure, respiratory failure, sepsis, multi-organ failure, decapitation, rigor mortis, tissue decomposition, or extreme dependent lividity. Sample The target population of this survey is SNFS in Michigan. Using random sampling technique, 200 SNFS were selected from 332 listed in the W o ital N , i s ..- -. "i 101‘ . he Mm M-u .. al 0 f i' i .rltr care pmgrams of Michigan (1222) published by the Michigan Department of Public Health. To complete the simple random sampling technique, each SNF listed in the directory was numbered 1-353. Slips of paper, same size and color were then numbered 1-353 and placed in a hat. The researcher drew from the numbers 200 times. Using the numbers selected, each SNF was identified in the directory and a master sample list was constructed. The names of the SNFS included in the sample were kept confidential with 23 the researcher. Instrument The written survey used in this study was developed by the researcher based on the survey instrument used by Levinson, et. al. (1987). Written permission was received from W. Levinson to use some of her survey questions. Additional questions were constructed by the researcher relating to advance directives. Four registered nurses, who participated in the collection and implementation of advance directives in local SNFS, read the survey for clarity and content. Recommendations concerning items 8d and 1 1c were included and consensus was reached on the survey questionnaire. The tool uses both forced answer and open ended questions for data collection (See Appendix A). Data Collection Procedure The survey was mailed to each target SNF (n=200), addressed to the Director of Nursing Service. The cover letter (appendix B) offered the participant a simplified description Of the purpose of the study, estimated time required to complete the survey, and assured the participant that privacy of each facility would be maintained. The cover letter served as informed consent and stated that by returning a completed survey the participant voluntarily consented to take part in the study. Eighty-seven completed surveys were returned to the researcher in an enclosed self-addressed stamped envelope. Fifty-three surveys were returned within 10 days of mailing the survey. Two weeks after the initial mailing, a second mailing of the same survey was made to all facilities and 30 completed surveys were returned within 10 business days. Two days before the completed surveys were to be returned, the researcher telephoned each participant to encourage completion of the survey and offer to mail a third copy if needed. One facility 24 requested a third mailing of the survey. Only 4 additional surveys were received following telephone contact. Total response rate was 87 out of 200 surveys mailed. Protection of Human Subjects This study was reviewed and approved by the University Committee on Research Involving Human Subjects of Michigan State University (Appendix D) prior to collection and analysis of data. All aspects of data gathered for this study were kept confidential. Anonymity of participants was maintained throughout reporting of results as no identifiers are given in the responses elicited. 25 Chapter 5 RESULTS As of July 1994, the time of the present study, there were 332 SNFS licensed and operating in the state of Michigan. Eighty-seven of the 200 randomly selected nursing homes returned the questionnaire (44% response rate). The research questions proposed in this exploratory study examined the practices related to eliciting advance directives, reviewing advance directives, documenting the advance directives, and implementing advance directives. Eliciting Advance Directives The data indicated that many SNFS elicited advance directives from residents on day of admission (n=39; 45%), whereas some facilities (n=22; 25%) inquire about advance directives prior to admission. Twenty-eight percent (n=24) of SNFS reported eliciting advance directives prior to admission and again on the admission day. Only 2% (n=2) of the SNFS gave residents 30-60 days post admission to declare an advance directive. The task of eliciting advance directives was a clerical role carried out by the admission clerk or bookkeeper in 20% (n=17) of the SNFS. Both the clerical staff and social worker were responsible for eliciting the initial advance directive in 22% (n=l9) of the SNFS. Most SNFS (n=47; 54%) assigned the task to the social worker. The administrator (n=1; 1%) and the admission nurse (n=2; 2%) were also mentioned. When the advance directive was elicited, the social worker formally talked with the resident in 35% (n=30) of the cases, or the nurse and social worker talked together with the resident 26 in 32% (n=27) of the cases, the nursing staff held the discussion in 14% (n=12) of the cases, and the whole interdisciplinary team talked with the resident in 13% (n=11) of the cases. In rare cases, either the Administrator or Director of Nursing spoke with the resident (each cited once). Reviewing the Advance Directive Seventy-eight percent of SNFS reported reviewing the advance directive/ resuscitation order at least annually (see Table 1 for breakdowns of specific times). The majority (75%) of facilities reportedly reviewed the advance directive/resuscitation status each time the resident’s condition worsened. When the resident’s condition changed, the T ' v ' e 'v v' w 13192221191 £1361 i Monthly 3 5 Quarterly Minimum Data Set 40 60 Semiannually 2 3 Annual Minimum Data Set 14 21 Not otherwise Specified 8 l2 nurse and/or social worker were most likely to review the resuscitation status with the resident (see Table 2). Of the SNFS surveyed, only 14% (n=14/86) had an ethics committee to help families and staff with end of life decisions. 27 10‘ mar 11-1.-. or! BespcnsitLleDngnline Nurse Physician Social Worker Director of Nursing Nurse, Doctor, Social Worker Nurse & Social Worker Nurse & Doctor ‘11.. 17 20 23 a. ‘ 20 23 26 Documenting the Advance Directive Most facilities denied recording subjective patient data surrounding the processes of deciding to declare or not declare an advance directive (n=63; 72%). Eight percent (n=7) of the SNFS stated they may record the discussion about the advance directive if it was not collected on admission per standard operating procedure, if the resident or DPOAHC changes the medical treatment plan from the original advance directive, or if the facility is concerned about disagreement between family members. Request to limit treatments were then recorded in the resident’s chart (see Table 3). Respondents reported that the request to limit treatment is noted in more than one place in the medical record; therefore, totals in Table 3 are greater than the number of respondents and greater than 100%. 28 Linden n_=_81 % Advance Directive Tab 30 35 Legal Document Tab 6 7 Front Cover 36 41 Admission Record 3 4 Face Sheet 7 8 Physician Orders 7 8 Nursing Notes 3 4 Social Service Notes 3 4 Physician Progress Notes 3 4 Miscellaneous Tab 1 1 Interdisciplinary Progress Note 3 4 Ancillary documents were frequently used to indicate CPR status, in addition to the chart placement of the advance directive (see Table 4). Identification bracelets were used to distinguish who has an advance directive to withhold/limit treatment verses receive CPR (n=17; 20% in of the SNFS). Other facilities had an indicator over the bed (n=5; 6%) or on the door to the resident’s room (n=4; 5%). T-I,‘ ‘ Du 11'15010 “VII ‘ ._’ V] in” o I‘M‘c. ai‘ rd flatten Frequency % Minimum Data Set 2 2 Care Plan 6 7 Kardex 4 5 Crash Cart 1 1 Emergency room 1 1 Medication Record 19 22 29 Implementing Advance Directives A physician’s order was reportedly required to implement a resident’s request to withhold CPR in 74% (n=64) of the SNFS. A nurse order to honor the advance directive may be written without a physician’s order in 24% (n=22) of SNFS, and one respondent reported being uncertain (1 %). When the DPOAHC requested that CPR be withheld, the nursing staff could initiate a "No CPR" status without a physician’s order in 30% (n=26) of the facilities, whereas 69% (n=60) of the SNFS still required a physicians order, and again one respondent was uncertain (1%). Six respondents (7%) acknowledged that they did not offer CPR to residents. Four of these facilities called EMS without initiating CPR by nursing staff. One such facility notified the sheriff of the death, and another reported that the Doctor notifies the family of the death. One facility reported requiring all residents have a "NO CPR" status as a requisite for admission. Overall, the majority of SNFS (n=81; 93%) did offer CPR. Of these, 95% (n=77) reported that CPR is initiated if the resident has not declared an advance directive contraindicating the use of CPR. A slim majority (n=49; 56%) of the facilities had guidelines for using professional judgement to withhold CPR, (see Table 5). Tu: , _ P be n1" t-‘ ‘O__'_Of‘ JOIL can: 0W1“... '1 Ratismale me u c Family request 3 Doctor order 5 Poor physical condition 2 Irreversibility of condition 4 Unwitnessed arrest 16 Advanced age 1 Signs of death 15 Terminal illness 1 EMS>15’ response time 1 30 Capacity for Providing CPR There were 73 respondents whose SNF offers CPR and who completed survey questions concerning the resources to provide basic life support within the SNF. A slim majority of SNFS required mandatory annual CPR renewal for nursing staff (n=37; 51%); 14% (n=10) had annual CPR renewal as a voluntary certification for nursing staff. Eighteen percent (n=13) of the SNFS provided voluntary annual renewal of CPR for all facility employees; seven percent of the SNFS required all employees renew CPR annually. Eleven percent (n=8) of the SNFS did not facilitate or require employee certification in CPR. With respect to equipment, the reported percentage of SNFS maintaining each type of equipment is listed below: supplemental oxygen was available through the use of nasal cannulas (n=53; 80%), face masks (n=56; 77%), Ambubag (n=60; 82%), one-way valved mouth mask (n=53; 73%), back boards (n=54; 74%), suction (n=66; 90%), artificial oral airways (n=55; 75%), and conjunctive intravenous catheters venous access (n=35; 48%). Almost one half (n=36; 49%) of the SNFS reported having the necessary supplies listed above as being kept together on a "crash cart," whereas the other SNFS (n=37; 51%) denied keeping these supplies located together for easy access. 31 Chapter 6 DISCUSSION Since cardiopulmonary resuscitation (CPR) became standard operating procedure for all patients experiencing cardiac or respiratory arrest, weighing the benefits for the use of CPR against the costs of withholding CPR has presented both ethical and moral dilemmas. This becomes more noticeable when treating victims of advanced age (Applebaum, King & Finucane, 1990; Awoke, Mouton, & Parrott 1992; Hanson & Danis, 1991). Through the 19808 and into the present, moral and ethical issues surrounding the appropriate use of CPR have arisen. In particular, economic and social influences have brought the use of CPR in elderly populations under scrutiny (Braithwaite & Thomasma, 1986; Gillick, 1988; Callahan, 1989, Hansen & Danis, 1991). Part of the debate to use or withhold CPR in elderly clientele parallels the transformation of nursing home care from a paternalistic method of health care delivery to a client-centered collaborative method of health care delivery. The philosophical change in nursing home care began with the Ombudsman Reconciliation Act of 1987, which is best remembered for defining and limiting the use of physical and chemical restraints. This legislation brought the Patient’s Bill of Rights to the forefront of client-centered care, creating a collaborative approach between families, patients, and health care providers. More recently, the Patient Self Determination Act of 1990 (PSDA) strengthens the momentum of client-centered care by emphasizing the patient’s rights in end of life decisions. The PSDA requires health care facilities receiving Medicare funds to inform patients of written policy regarding the 32 implementation of CPR, the patient’s right to declare an advance directive, and the patient’s right to declare a durable power of attorney for health care (DPOAHC). Prior to the PSDA few nursing homes had written policy guiding the practice of implementing CPR (Miles &Ryden, 1985; Lipsky, Hickey, & Browning, 1989, Levinson, Shepard, Dunn, & Parker, 1987). In fact, nursing homes did not provide access to quality care through the use of basic CPR (Levinson, Shepard, Dunn, & Parker, 1987). These studies revealed the focus of nursing home care was to provide death with dignity. As long term care delivery transformed from the medical model of paternalistic care to a social model of client-centered care, the focus of patient care shifted to individualized care which promotes dignity, independence, and freedom of choice. To date, there is little research available which describes current policy and practices regarding advance directives and CPR in SNFS. The purpose of this study is to describe current SNF policy and practices surrounding the use of advance directives and the use of CPR. This study specifically addresses practices for eliciting advance directives, policy concerning the use of CPR, and facility capacity to provide basic life support. Summary of Findings Consistent with the literature, the present study demonstrates that there is little written documentation in the chart to support collaboration between physicians, patients, and proxies when declaring an advance directive or "NO CPR" status (Berlowitz, Wilking, & Moskowitz, 1991; Finucane & Denman, 1989; Kohn & Menon, 1988; Meyers, Lurie, Breitenbucher, & Waring, 1990). This researcher found that 80% of the SNFS responding do not require written documentation concerning discussions of advance directives. It is known that the patient or patient’s family preferred to review 33 advance directive status with the nurse rather than other disciplines (Bachelor, et. al., 1992); the present study demonstrates that current SNF practice diminishes the process of eliciting advance directives to a clerical task delegated to multiple disciplines and support staff. Only 14% of the SNFS surveyed report nursing as the primary discipline responsible for eliciting and reviewing advance directives. This study shows that most SNFS (75%) review the advance directive each time the resident’s condition worsened. In such instances, the nurse and/or social worker were identified as the discipline(s) most likely to review the resuscitation status with the resident (nurse=20%, social workem10%, nurse & social worker dyad =26%). Physicians were not involved in the elicitation of advance directives and were rarely involved with the advance directive review with a significant change of condition. Regardless of advance directive status, nursing staff may use professional judgment to override the resident’s request for CPR in the majority of nursing homes (56%). Findings are consistent with the American Medical Association Council on Ethical and Judicial Affairs recommendations for using medical futility as just cause to withhold CPR regardless Of patient request for CPR. Additionally, SNF policy allows for professional judgment to withhold CPR for unwitnessed arrests and geographic isolation from EMS. The present study demonstrates that although professional judgment may be used to override the patient’s choice for CPR, the focus of SNF care is no longer concentrated on palliative care. N inety-three percent of the respondents report offering CPR as a treatment option. Only one respondent requires a "do not resuscitate" status for admission to the SNF. Similar to past research, the present study demonstrates that SNFS still do not maintain adequate resources to provide basic CPR. Of the SNFS which can 34 and do offer CPR, most do not meet the standard of care for providing safe and effective CPR. Less than half the facilities report keeping supplemental equipment gathered together on a crash cart, for easy emergency access. The present study suggests that the elicitation of advance directives in SNFS has been simplified to a clerical task in order to fulfill the PSDA mandate. On the other hand, advance directives are usually reviewed by professionals with health care knowledge (i.e., nurse and/or social worker) when there is a significant change of condition. Current SNF practice endorses the use of professional judgment to override the resident’s request for CPR in the instances of medical futility; however, only 14% of the SNFS have a formalized ethics committee to assist families and staff with do not resuscitate decisions. The majority of SNFS acknowledge CPR as a treatment option but slightly more than half (51%) require nursing staff to maintain certification in CPR or organize emergency equipment for easy access (e.g., crash cart). Limitations Of the Present Study Although the simple random selection technique strengthens the generalizability of the data, three limitations need to be considered when interpreting the study results. Firstly, the survey had only a 44% response rate (200 surveys were mailed with 87 returned); however, the raw number of respondents is consistent with other studies found in the literature. Secondly, the questionnaire did not verify that the SNF had Medicare certification at the time Of the survey. And lastly, in hopes of getting honest answers about sensitive issues, no descriptive data was collected about the SNFS (such as proprietary status, religious affiliation, Size, location, etc.). Therefore, no comparison can be made by categories of SNFS. 35 Implications for Practice Given that patients and families prefer to confer with nursing about end of life decisions, (Bachelor, et. al., 1992) the role of nursing is currently underscored in eliciting advance directives. The unique nurse-patient relationship is a key element to insuring quality Of care consistent with the social model of patient care. In order to deliver true client-centered care which promotes independence, dignity, and freedom of choice, nursing needs to have a more active role in the elicitation of informed decisions concerning the declaration of advance directives. The tasks of eliciting, reviewing, and implementing advance directives should remain a nursing responsibility rather than a delegated or assigned task. Advanced practice nurses have the skills necessary to not only demonstrate but advocate for this important nursing role. From a population management perspective, the nurse serves as a case manager who leads care plan formulation, implementation, and evaluation. In order to provide the minimum standard of care concerning CPR, the nurse employed in SNFS must have the professional integrity to maintain CPR certification even though professional licensing does not require certification in CPR and employing agencies may not facilitate easy renewal of CPR certification. Since it the nurse who coordinates emergency transport, other trained staff must be available to provide CPR at the bedside. That is, all staff should be competent in performing CPR, in order to assure access to quality care. Additionally, nurses need to be aware of employing facilities’ capacity to provide CPR, as it directly affects the nurse’s ability to perform his or her job safely and effectively. Nurses also must be knowledgeable in the operational definition of medical futility and facility policy and procedure for utilizing professional judgment to withhold CPR. 36 Since the majority Of nurses working in SNFS are licensed practical nurses, supervised by registered nurses who typically have diploma or associate degrees in nursing, the researcher suggests that the advanced practice nurse in gerontology should consult with SNFS in order to develop facility policy and reform nursing practice related to advance directives and CPR. As experts in geriatric health care, advanced practice nurses in gerontology have advance training in counseling, educating, collaborating, patient advocacy, and policy development. These roles are necessary components to facilitate decisions regarding advance directives, end of life treatment plans, and development of sound practice. The Need for Future Research Further research is needed to validate the findings of the present study. Future research could test if there is a difference in SNF capacity to provide CPR by geographic proximity to hospitals or EMS services, proprietary status, and religious affiliation of the SNF. Many research opportunities encompassing the decision-making process to implement or withhold CPR could examine sociocultural economic factors of the individual, DPOAHC, and provider(s). The communication between client, DPOAHC, and provider(s) needs to be examined for congruency in selecting treatment options. The relationship of the nurse, client, and DPOAHC could be studied tO see how it changes across time as the client experiences functional decline. When and to what extent does power shift as the individual becomes incapacitated? Lastly, the knowledge and values of nurses employed in SNFS need analyzing. Do nurses maintain CPR certification as a professional value? DO nurses in SNFS know and understand the legal use of medical futility for withholding CPR? When and how frequently to nurses utilize medial futility 37 to withhold CPR? Only by surveying nurses’ attitudes, knowledge, and current practice concerning the elicitation and implementation of advance directives and the use of CPR, will we learn if the PSDA is Shaping a philosophy of client-centered care in SNFS. 38 REFERENCES 39 REFERENCES Act No. 493 of Public Acts of 1978. State of Michigan 79th legislature. 816. Applebaum, G., King, J., &Finucane, T. (1990). The outcome of CPR initiated 1n nursing homes WWflLL 197 200 Awoke, S., Mouton, C., & Parrott, M. (1992). Outcomes of skilled cardiopulmonary resuscitation in a long-term care facility. Futile therapy? W AmmeanfienatnesimetxtfiQLQWS- -.595 Bachelor, A., Winsemius, D., O’Connor, P., & Wetle, T. (1991). Predictors of advance directive restrictiveness and compliance with institutional policy in a long-tenn care facility- InumfloflheAmenoanfledatnesSmm £411). 7.. 679-684. Berlowitz, D, Wilking, S., &Moskowitz, M. (1991). Do- not- resuscitate orders at a chronic care hospital WW £321. 5. 472476 Braithwaite, S. & Thomasma, D. (1986). New guidelines on foregoing life-sustaining treatment in incompetent patients: An anticruelty policy. Annals of mtemal Medicine. (1241.5, 711-715. Callahan, D. (1989). Old age and new policy. WWW Manon. IZQLL Q. 905-906. Council on ethical and judicial affairs, American Medical Association (1991). Guidelines for the appropriate use of do- not- resuscitate orders. MW MedicaLAssocianonafliIli 1868- 1871. Council on ethical and judicial affairs, American Medical Association (1992). Decisions near the end of life. mammmmm (2611. In. 2229-2233. Durable power of attorney for health care and appointment Of a patient advocate. (1991) published by the Michigan Association of Osteopathic Physicians and Surgeons, Inc. Duthie, E., Mark, D., Tresch, D., Kartes, S., Nearhring, J ., & Aufderheide, T. (1992). Utilization of cardiopulmonary resuscitation in nursing homes in one community; Rates and nursing home characteristics. W Sgg'efl, (41), 4, 384-388. Ebell, M., Eaton, T. (1992). Flow chart for the interpretation of do- not- resuscitate orders statutes IheloumaLoLEamrleracuce. 1.351. 2. 141-143 40 Emanuel, L. (1991). The health care directive: Leaming how to draft advance care documents WWW I321. 22. 1221- 1228 Gillick, M. (1988). Limiting Medical Care Physician; beliefs, physicians’ behavior lonmalctmeArnericanfieriatricsmietLQQLE747- -752 Hanson, L. & Danis, M. (1991). Use of life sustaining care for the elderly. InumalmtheAmencanflcnmmL Q21. 22. 772- 777. Levinson, W, Shepard, M, Dunn, R, &Parker, D. (1987). Cardiopulmonary resuscitation in long- -term care facilities. a survey of do- not-resuscitate orders In nursing homes Wflflm 1059- 1062 Meleis, A. (1991). Theoretical nursing development and progress, 2nd edition. pp. 393-399. Philadelphia: J .B. Lippincott Co. Michigan Department of Public Health, Bureau of the Health Systems. (1992). _'I-o.o.oo..__ i ‘ “It tr; Q“ --_-...I WPagelA Miles, 8., &Ryden, M. (1985). Limited- treatment policies In long term care facilities IoumaLnLtheAmericanfiedatthflocmL (.13).. 112. 707- 71 1 Omnibus Reconciliation Act of 1990. Title IV, Section 4206. Congressional Record 1221; 136:H12456—12457. Orem, D. (1980). W, (2nd ed.). New York: McGraw-Hill. 96-103. Orem, D. (1985). W, (3rd ed.). New York: McGraw-Hill. Orem, D. E. (1987). Orem’ 8 general theory of nursing. In R. Parse (Ed), Nurr ris ng WWOP 67- 89) Philadelphia: W..B Saunders. Payne, J. (1989, September). The ABCs of resuscitation equipment. 113 Canadian Nurse. 26-27. Public Law 101-508. 104 STAT. 1388-116. 42 United States Congress. Sommers, M. (1992). The shattering consequences of CPR. Nursing ‘22, (2), 7. 34-41. Standards and guidelines for cardiopulmonary resuscitation and emergency cardiac care (1986). IoumalnttheAmeernMeflcalAssncjation. £255) (21.), 2915-2931. 41 Standards and guidelines fore cardiopulmonary resuscitation and emergency cardiac care: Part 111 adult advanced cardiac life support (1986).,191ImaLQflheAmeLgL MediclLAssnciation 125.51.2L 2933- 2951. Standards and guidelines fore cardiopulmonary resuscitation and emergency cardiac care: Part VI Medicolegal considerations and recommendations (1986). Journal oLtheAmcncanMEalAsmm £25.51. 2L. 2979-2984. Tresch, D. (1991), CPR in the elderly: When should it be performed? Geriatrics. (46), 1; 47-56. Uhlman, R., Pearlman, R., & Cain, K. (1988). Physicians; and spouses’ predictions of elderly patients’ resuscitation preferences. e a1 1 (43), 1115-121. White, M. & Fletcher, J. (1991). The patient self-determination act on balance, more help than hindrance IonmaLoflheAmeanedrMIancn. 1226). 3. 410-412. Wynne, G. (1990). Revised guidelines for life support. W (83), L 70-74. 42 APPENDICES 43 APPENDIX A DATA COLLECTION TOOL DATA COLLECTION TOOL 1. During the last six months, what was the average daily census?___ 2. What is the average length Of stay for your residents based on the last six months for: a. Skilled beds __ b. Intermediate beds _ c. Assisted Living __ 3. How many physicians have privileges in your facility? __ 4. Does the medical director also serve as the house physician? Yes __No _ 5. What percent of the residents use a house physician as the primary physician? _ 6. How many Nurse Practitioners have privileges in your facility? __ 7. What percent of the residents use a Nurse Practitioner as their primary provider? 8. How soon are residents given information about advance directives in relation to their admission? a. Preadmission b. Day of admission c. Within 30-60 days after admission d. Within 90-180 days after admission 9. Who is responsible for informing the resident of his right to declare an advance directive? a. Admission Clerk/Book keeper b. Admission Nurse c. Social Worker (1. Physician e. Other 10. After admission, are resuscitation orders routinely discussed with every patient and/or their family? a. Yes b. No (if no skip question 11) 45 11. 12. 13. 14. 15. 16. 17. 18. With what frequency after admission is the resident asked to consider his/her Do Not Resuscitate status (circle all that apply): a. Monthly b. Quarterly with Minimum Data Set review c. Semiannually d. Annually, with annual Minimum Data Set review e. Other Is the advance directive reviewed when the resident’s condition worsens? a. Always b. Never 0. Sometimes If so, who reviews the advance directive with the patient and/or Durable Power of Attorney? a. Nurse b. Physician c. Social Worker (1. Other When advanced directives are elicited, who formally talks with the resident and/or family? a. Resident’s private physician b. House Physician c. Nurse Practitioner d. Nursing staff e. Social Worker f. Clergy g. Other (specify) Is the discussion of advance directives recorded in the medical record? a. Always b. Never c. Sometimes, if so specify when If so, what discipline is primarily responsible for documenting the discussion? If the patient writes a living will requesting that CPR be withheld, can the nursing staff initiate a "NO CPR" status or "Do not resuscitate" status in the medical record without a physician order? a. Yes b. No c. Uncertain Where are requests to limit treatments (e.g., NO CPR, NO tube feedings, No ventilators, etc.) recorded? (Circle all that apply) a. Front of resident’s chart b. In resident’s medical record (where specifically) c. Medication administration record d. Identification bracelet e. Other__ 46 19. 20. 21. 22. 23. 24. 25. 26. 27. If the Durable Power of Attorney requests that CPR be withheld, can the nursing staff initiate a "NO CPR" status or "Do not resuscitate" statUs in the medical record without a physician order? a. Yes b. No c. Uncertain Does your facility have an Ethics Committee to assist families with DO Not Resuscitate decisions? a. Yes b. No Approximately what percent of the residents in your facility have DO Not Resuscitate orders? Does your facility provide cardiopulmonary resuscitation? a. Yes b. NO Does your facility provide cardiopulmonary resuscitation in the absence of an advance directive? a. Yes b. No How many times last year was CPR performed? How many deaths occurred within the facility last year? If the staff does not perform CPR, what action is taken by nursing when a resident without an advance directive experiences respiratory or cardiac arrest? If your policy state that the staff may initiate CPR in the event of cardiac/respiratory arrest when not contraindicated by a advance directive, WHAT GUIDELINES are nurses to use to determine withholding CPR? 47 28. If the facility provides CPR, please circle the method by which your staff is certified. a. 6. Voluntary annual renewal of basic life support sponsored by the facility for all employees. Voluntary annual renewal of basic life support sponsored by the facility for nursing staff only. Mandatory annual renewal of basic life support sponsored by the facility for all employees. Mandatory annual renewal of basic life support sponsored by the facility for nursing staff only. None of the above. 29. If the staff performs CPR with oxygen therapy, please circle all of the resources listed below which are available in your facility: a. nasal cannula b. face mask c. arnbubag d. one-way valved mouth mask 30. Please indicate which of the following equipment is available for implementing CPR: a. Back board (circle if the headboard of the bed liftoff and are used as substitutes for backboards) Suction machine with 300mm HG capacity of suction Artificial oral airways Intravenous catheters for insertion and subsequent intravenous fluids or a heparin lock. 31. Is the equipment listed above collected and kept ready for use on a "crash cart"? a. Yes b. No Thank you for completing this questionnaire. Please return the completed form in the self-addressed stamped envelope provided for you. If you would like the results of this survey, please return the enclosed postcard separate from your completed questionnaire. Debra Zakrajsek, R.N., B.S.N. 48 APPENDIX B COVER LETTER FOR SURVEY 49 COVER LETTER FOR SURVEY July 6, 1994 Dear Colleague, As a candidate for Master’s of Science in Gerontology Nursing at Michigan State University, I am currently investigating the role of nursing in relation to advance directives in long term care facilities throughout Michigan. The purpose Of this exploratory study is to describe the role of nursing in teaching residents and families about advance directives, the development of Do Not Resuscitate orders, and initiating Cardiopulmonary resuscitation. Attached you will find a 27 question survey; it takes approximately 30 minutes to complete. Results of the survey will be summarized so that anonymity of each participating facility is maintained. If you have any questions regarding the purpose of the survey or need clarification of a question please call me at (517) 676-2842. Participation in this study is voluntary. You may leave questions blank. This letter serves as notice of informed consent. You indicate your voluntary agreement to participate by completing and returning this questionnaire. Thank-you. By answering this survey, you are participating in the advancement of nursing as a profession. Sincerely, Debra Zakrajsek, R.N. Candidate for Master of Science in Nursing Michigan State University 50 APPENDIX C COVER LETTER FOR SECOND MAILING 51 COVER LETTER FOR SECOND MAILING July 20, 1994 Dear Nurse Colleague, Enclosed is a survey assessing practices surrounding the Patient Self Determination Act in nursing homes. This is a second mailing of the same survey mailed earlier this month. If you previously completed this survey please disregard this present mailing. If you had not received or did not have enough time to complete the survey, I would greatly appreciate data from your facility by August 1, 1994. Please complete this survey only if you have not previously done so. Please be advised that participation in this study is voluntary and all forms are anonymous. Please return the completed survey in the envelope provided. Sincerely, Debra Zakrajsek, R.N., M.S.N. Candidate Michigan State University College Of Nursing A230 Life Sciences Bldg. East Lansing, MI 48824 52 APPENDIX D PROTECTION OF HUMAN SUBJECTS 53 flfl!54flh we 517/3341" WHOM Appendix D Protection of Human Subjects MICHIGAN STATE UNIVERSITY June 27. 1994 r0: Debra Sakrajsek 648 H. Columbia St. Mason. MI 48854-1024 RE: 138‘: TITLS: A DESCRIPTION OP PRACTICES SURROUNDING THE P,TISNT SSLP DETERMINATION ACT IN NURSING HOMES g:VISION REQUESTED: N A RY: -C APPROVAL OATS: 06/27/94 Theioniversity Committee on Research Involving Human Sub rev ew of this reject is complete I am leased to advI::tEhA2cEE:8) r hts and welfare of the human . p sub ects appear to be ad atel p tected and methods to obtain in! rmed consent are app pria . 1i§§3§°§§6 the ucnrns approved this project including any revieion ve. RENEWAL: UCRIHS approval is valid for one.calendar year, beginnigg with the approval date shown above. Investigators planning continue a project be nd one year must use the green renewal form (enclosed with t e original a roval letter or when a project is renewed) to eeek u t certification. There is a .IEhin of four such expedit renewals ssible. Inventigators w 2 to continue a reject beyond the time need to submit it again or complete rev ew. REVISIONS: UCRIRS must review any changee in rocedures involving human subjects, rior to in tiation of t e change. If this is done at the time o renewal, pleaee use the reen renewal form. revise an approved protocol at an‘ 0 her time during the year send your wr tten request to the CRIBS Chair, requesting revised approval and referencin the project's IRS # and itle. Include in our request a descr ption of the change and any revi eed ins ruments, consent forms or advertisements that are applicable. PRODLBKS/ CHANGES: Should either of the followin arise during the course of the work. investi ators must noti y UCRIBS promptly: l) groblems (unexpected s de effects comp aints, e c.) involv g uman subjects or 12 lchanges in the research environment or new n information eating greater risk to the human egggecte than existed when the protocol was previously reviewed I I! we can be of any future helg p do not heeitate to contact us at (517)355-2180 or tax (517): 8- 1 1. Sincerely, vid S. Wright. DCRIHS Chair DSW:pjm cc: Joan Predko 54