Carpenter, Christopher R

Cooney, Timothy

Mirarchi, Ferdinando

Renz, Nicholas

Sampson, Christopher

Stickles, Sean

Wagner, Jason

Digital Commons@Becker

Washington University School of MedicineDigital Commons@BeckerConference Abstracts and Posters Division of Emergency Medicine/Emergency CareResearch Section2013Does a phyisician advanced directive survey predictbedside response in simulated end of life scenarios?Christopher R. CarpenterWashington University School of Medicine in St. LouisTimothy CooneyWashington University School of Medicine in St. LouisJason WagnerWashington University School of Medicine in St. LouisChristopher SampsonWashington University School of Medicine in St. LouisNicholas RenzWashington University School of Medicine in St. LouisSee next page for additional authorsFollow this and additional works at: http://digitalcommons.wustl.edu/em_confThis Presentation Poster is brought to you for free and open access by the Division of Emergency Medicine/Emergency Care Research Section atDigital Commons@Becker. It has been accepted for inclusion in Conference Abstracts and Posters by an authorized administrator of DigitalCommons@Becker. For more information, please contact engeszer@wustl.edu.Recommended CitationCarpenter, Christopher R.; Cooney, Timothy; Wagner, Jason; Sampson, Christopher; Renz, Nicholas; Stickles, Sean; and Mirarchi,Ferdinando, "Does a phyisician advanced directive survey predict bedside response in simulated end of life scenarios?" (2013).Conference Abstracts and Posters. Paper 2.http://digitalcommons.wustl.edu/em_conf/2AuthorsChristopher R. Carpenter, Timothy Cooney, Jason Wagner, Christopher Sampson, Nicholas Renz, SeanStickles, and Ferdinando MirarchiThis presentation poster is available at Digital Commons@Becker: http://digitalcommons.wustl.edu/em_conf/2BACKGROUND                                       Advanced directives (AD) are intended to direct patient’s future medical care during periods of decision-making incapacity  Professional societies advocate AD to support patient autonomy and promote nonmaleficence  Emergency medicine (EM) graduate medical education leaders identify obtainment and interpretation of AD as a minimal core competency for residents  OBJECTIVES                                      •  To assess EM resident accuracy in interpreting AD in the emergency department (ED) during simulated acute life-threatening medical events • Secondary objective to evaluate differences in interpretation or clinical actions between an online AD survey and the identical simulation scenario  METHODS                                          •  Single academic medical center observational study of consenting EM residents, adhering to Strengthening of Reporting of Observational Studies in Epidemiology (STROBE) criteria • All participants completed online AD survey 2-months prior to a regularly scheduled simulation session • Survey included participant demographics as well as six typical emergency scenarios with each case descriptor preceded by an AD (Boxes 1 and 2) • Respondents assigned a code status and next most appropriate intervention for each patient  • The simulation lab occurred over 4-hours on one day and used the same 6 scenarios evaluated in the pre-simulation survey • Participants were not reminded of the pre-survey and were asked to assign a code status using an electronic audience response system within 20-seconds after receiving the pre-hospital report • Pre- and post-survey responses analyzed using contingency table analysis (Chi-square, Fisher’s Exact Test)     Does a Physician Advanced Directive Survey Predict Bedside Response in Simulated End of Life Scenarios?  Christopher Carpenter MD MSc,1 Timothy Cooney,2 Jason Wagner MD,1 Christopher Sampson MD1 Nicholas Renz MD, 1 Sean Stickles MD,1 Ferdinando Mirarchi DO2  Divisions of Emergency Medicine 1Washington University in St. Louis School of Medicine, 2UPMC Hamot Medical Center  RESULTS                                              • A total of 47 residents completed either the pre-survey or the simulation lab, but only 17 completed both • The 17 completing both surveys did not differ significantly from the 30 who did not by any demographic parameter measured (Table) • Of the 26 pre-simulation respondents:    69% assigned a DNR code to AD scenarios and 64% did not enact life-saving measures   senior residents (PGY 3 or 4) assigned DNR more frequently (81% vs. 60%) and were less apt to elect life-saving interventions (21% vs. 49%, p>0.05) • Among the 29 simulation residents:  50% interpreted the AD as DNR and 40% did not attempt any resuscitation   resident training level (PGY 3 or 4 vs. PGY 1 or 2) did not impact code status assigned (51% vs. 53%), but senior level residents more often opted for resuscitation (72% vs. 57%, p > 0.05) • In the simulation lab resident training level did not impact code status assigned, but senior-level residents more often opted for resuscitation  CONCLUSION           •  In assessing EM resident AD clinical response, physicians are more likely to provide life-sustaining actions in simulation than in internet surveys • Senior-level residents tend to disregard AD more commonly in simulation than in surveys            Table:   Descriptive Statistics for 17 Participants Completing Pre- and Simulation-Survey (N = 17) Descriptor Value (mean or proportion) Age 30 ± 3 Male Gender 71% Prior AD Training 0% Medical School Region    Midwest    South    Northeast    West   65% 29% 0% 0% Resident Level    PGY I    PGY II    PGY III    PGY IV  29% 35% 12% 24% Box 2:  Sample Scenario 46 –year-old female presents with complaints of chest pain, shortness of breath and diaphoresis.  Vitals: T: 37C, P: 110, BP: 130/70, RR: 30, SaO2: 97%.  The patient has been given oxygen, aspirin, and nitroglycerin en route.  Pre-hospital ECG shows acute anterior wall STEMI.  EMS presents you with a list of medications and their living will.  Abruptly her status changes as you evaluate her.  She becomes unresponsive and develops VT/VF arrest.   Question 1:  What is her code status based on her living will? a) DNR b) Full Code   Question 2:  What is the next course of action? a) Defibrillate b) Don’t defibrillate Box 1:  Sample Advanced Directive  (My specific instructions to my family and health care providers)   I,        , being of sound mind, willfully and voluntarily make this declaration to be followed if I become incompetent.  This declaration reflects my firm and settled commitment to refuse life-sustaining treatment under the circumstances indicated below.  I direct my attending physician to withhold or withdraw life-sustaining treatment that serves only to prolong the process of dying, if I should be in a terminal condition or in a state of persistent unconsciousness.  I direct the treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that might occur by withholding or withdrawing life-sustaining treatment.  In addition, if I am in the condition described above, I feel especially strong about the following forms of treatment:   I (  ) do (x) do not want cardiopulmonary resuscitation. I (  ) do (x) do not want electroconversion. I (  ) do (x) do not want mechanical respiration. I (  ) do (x) do not want tube feeding or any other artificial or invasive form of nutrition (food) or hydration (water) I (  ) do (x) do not want blood or blood products. I (  ) do (x) do not want any form of surgery or invasive diagnostic tests. I (  ) do (x) do not want kidney dialysis.   After reading this Living Will, how do you interpret the following questions for an individual patient in the ED? 

Does a phyisician advanced directive survey predict bedside response in simulated end of life scenarios?

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Does a phyisician advanced directive survey predict bedside response in simulated end of life scenarios?

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