February 28, 2020
What Does That DNR Really Mean? w/Dr. Fred Mirarchi | Incident Report 246

What Does That DNR Really Mean? w/Dr. Fred Mirarchi | Incident Report 246

Yo, what’s up Z-Pac? It’s your boy ZDoggMD,
welcome to Incident Report. Today’s guest is gonna teach us a lot about end of life directives, and he knows his stuff because
he’s an emergency physician, he’s also the Chief Medical Officer of the Institute on Healthcare Directives, and the founder of a really
cool startup called MIDEO. It’s a video-based app where you can tell your healthcare team in emergency settings what the heck you want if
the stuff hits the fan. We have Dr. Ferdinando
Mirarchi here with us. Fred Mirarchi what’s up? – How are ya? Thanks for having me. – [Zubin] Dude it’s a pleasure, ’cause you’re a brother
from another mother ’cause you’re an
emergency doc from Philly. – That’s it, I’m from Philly. – It’s pretty hard core. You don’t have a North Face
jacket or the spandex though, and that’s upsetting to me because you’re not playing the type. – Yeah, when I look at my
emergency medicine docs, I mean, they all wear it. They are all in the gear and so on and maybe I just don’t get outside enough. I live in Erie now, so I should
have North Face and spandex, I should have all that stuff to keep warm. – You ought to be para-snorkeling, doing all this extreme stuff right? But you were telling me
earlier, before the show, it’s interesting because you actually run emergency department programs. – I do. – And one of your sort of claims to fame is trying to bring together
my people, my tribe, our people call it mays,
hospitalists and emergency docs. And what’s that like? Is that like fire and ice? Is it like Game of Thrones? – So initially, fire and ice. But when you can make synergies
with different practices and specialties and really
develop, essentially, incentive models and collaborative
working relationships around it, man the synergy
can just be amazing. And we’ve been able to do that. We’ve been able to build
contracts for ER docs as far as incentives,
hospitalists as far as incentives, mutually aligned incentives, so you’re not just admitting
crap to the hospital, you’re admitting sick stuff that you really need
to keep in a hospital. And the same thing, we
get the hospitalists to work with us to do the beck
and works we have capacity. – Okay, how dare you call a 90 year old with a sodium of 134, that gets admitted for that sodium, crap. All right buddy. (laughs) By the way, you use so much
administrator speak there, synergy and aligned
incentives and you know what? I’m gonna compliment you for it because as a physician,
we need to be leading. We need to take that language
and actually implement it, because we know we
actually touch patients. – So it’s great. So when I talk to the
administrators in my system, they’re asking me when
I working clinically. And if I show up in business casual stuff and talk to the docs, they’re like, “Okay, are you administrator today?” It’s funny, I just, I
get it on both sides. – You can’t win, you can’t win. Well it’s interesting
because that actually ties in to the central premise of this episode, which is, you saw a problem as a clinician and what was that problem? – So I’ll go back to my own story. When I was an intern, back in 1997, I was taking care of a
55 year old lady in ICU. And I was a real aggressive intern and she went into V-tach
and I came running in looking to shock her, old
fashioned paddles, as old as I am. – Did you rub them together like on TV? – Absolutely, gel and
everything, holy crap. So I go to shock her and this nurse comes flying across the room saying, “No, she’s a DNR, she’s a DNR,” she’s flashing a living
will in front of me. And I was paralyzed. This lady’s dying in front
of me, I was paralyzed. And I was lucky, there
was a cardiologist there and he just threw me aside,
literally threw me aside, took the old fashioned
paddles, shocked her, she woke up, back then we
gave her a streptokinase, she lived, she went home to her family. If that were me, she’d be dead, you know. And then, if you fast-forward
just a little bit more, my intern, or not my
internship, but my residency, Alleghany General Hospital
in Pittsburgh, great system. Essentially, I’m taking care
of a patient who’s 65, septic. He came in, he had a living
will in front of him, I’m like, I’m not gonna
make this mistake again, so I treated the crap out of him, I intubated him, put lines in him, just to find out he was a
hospice patient, end stage, and his family just couldn’t
cope with him dying at home. So now I over-treated somebody. And then I came down to it and
found out in my own family, it was really hitting home, in that my father ended up passing away from spinal osteomyelitis
because his nurse thought his DNR made him
an end-of-life patient and didn’t take care of him
when he was critically ill. – It’s that tragedy of
DNR equaling do not treat or the DNR being overthrown
by an emotional family or a million different reasons we get the end-of-life piece wrong. – Absolutely. – Actually, before the show you were chastising me a
little bit, not so much, but more like, “Hey, I saw your
video on end-of-life stuff.” So you vein the way to die, where we talked about not
having the conversation and then being tortured
at the end of life. And you know, I have a strong bias, right, because as a hospitalist, I see what happens when we
don’t have the conversation and then people are flogged. So I have a certain bias. So the second video I
did where I was like hey, this is what actually happens
when we resuscitate you. We’ll put in tubes, you’re gonna get this, there’s gonna be
something in your wee wee. It’s a mess that you don’t see on TV. And all that is true,
but what you’re saying is we often miss that other side of it, which is, patients don’t understand and caregivers don’t understand that do not resuscitate doesn’t, it’s not just as simple as that. People have very nuanced wishes and we’re not able to communicate those, especially through, say,
paper or electronic charting. – Yep, so a couple things. I mean when you look at
it, first and foremost, there’s a body of
research called the TRIAD, it’s the realistic interpretation
of advanced directives. It’s in its 12th study now, as far as from anything from looking at living wills
to simulation trials. And I can show you
those, but the premises– – [Zubin] We’ll link to it. – Okay great. The premise has been true,
ever since the beginning. Health care is not ready
to deal with living wills. Health care providers are not ready to deal
with POLST documents. They’re good documents,
as everything has evolved, but they have issues or
unintended consequences with them. The unintended consequences
are living wills get misinterpreted as do
not resuscitate orders. They’re negatively expressive documents, they get misinterpreted. You show a doc that,
you show a nurse that, you show a paramedic that, a doc, 80% of the time will look at a living will and perceive it to be a DNR, a nurse 88% of the time, a
paramedic 94% of the time, will look at a living will
and assume it’s a DNR. When you ask these providers what their understandings
of DNR are, it’s flawed. 64% of physicians think
it means end-of-life care, 80% of nurses think it’s end-of-life care, 96% of pre-hospital providers
think it’s end-of-life care. So we have an issue here that
we’ve unleashed some things, hopefully for the good, but unintended consequences of
health care not being ready. And we have unfunded mandates that people have to
know about living wills, we have to ask them about living wills, we try and get systems
to make POLST documents, which are good. But we gotta make sure providers are ready to deal with them. And I was a victim of it, I was not ready to deal with it when I came out into my internship and I see it all the time in my residency, or in my residency I saw it all the time, and as an attending, I still see it today, that people make these
same misunderstandings. – With your father, what happened? – So my dad was an
immigrant to the country who, at one point in time, developed a very crippling
rheumatoid-like arthropathy, ended up in a rehab facility, got a urinary tract infection,
was becoming bacteremic. They saw his DNR order, which again, was just for cardiac arrest,
not for anything else, and essentially perceived him
to be an end-of-life patient, left him alone for 20 hours in a bed. – [Zubin] Septic. – Septic, bedsore septic and died. And that stuff happens
and we gotta make sure that those people really get
care when they want care. So going back to your video, great video. It shows, look, we all have
moral fatigue from this. You see them, I see them, the worst thing an ER doc wants to do is resuscitate a 90 year old
who’s got no quality of life or who has no chance of survival, but it’s a full code, oh my God, c’mon. Just like you guys, you don’t want that. We wanna put that person in
palliative care, into hospice, make sure they’re comfortable,
family’s protected and so on. But the reality of it is, is we’re scaring people
into making DNR decisions because we think everybody else is gonna understand what
they meant by that DNR order. And think, me and you could have a great conversation, right. You could know exactly what I want, you make me sign a living will
or you make me sign a POLST, great, we did a good job. We can even bill for it now. But when you go to the next step, when that next person
comes into their care, they have no idea,
we’re medical strangers, I don’t know you. – [Zubin] Medical
stranger, I love that term. – Medical stranger danger all over again. It’s stranger danger for kids, it’s stranger danger for patients today. Doctors don’t come to the hospital, so if we had that great conversation, you’re not there to support me, you’re not there to defend my rights and decisions as a patient. You got Fred Mirarchi, ER
doctor who doesn’t know you, who’s gotta look at a piece
of paper and within seconds, need to know how to treat you. That becomes the error. And when you see what happens
in the system, it’s broken. First, you can’t find documents. And maybe that’s good,
because if they found them, maybe more errors occur,
because patients are now, families are now finding out that patients aren’t being
treated, or worse yet, we’re starting to be sued now because we’ve treated somebody,
as far as saving their life. They call it wrongful
prolongation of life. So now we have this whole
new opening of a box that’s gonna cause lawsuits to physicians and health care systems and
they’re already happening. You don’t even have to
wait for them to happen, they’re already happening. – So it sounds to me
like what you’re saying is the communication
and the infrastructure to relay patients’ wishes is flawed and our ability to use that data is flawed in its current incarnation. So it’s not as simple as DNR, DNI. Like your father, he was do not resuscitate
for cardiac stuff, like if there’s cardiac arrest, but didn’t mean do not treat his urinary sepsis or bedsores
or these other things. And it’s true, I think a lot of caregivers just sort of turn off, if somebody’s do not resuscitate or they have a living will
or a MOLST or a POLST, physician orders on life
sustaining treatment. And we’ve had great guests on here talk about how to fill those out. And look, it’s very
important, like you say, but you have to be able
to interpret it correctly. And another thing you
said that was interesting was the medical stranger piece. So okay, Fred, Zubin, we’re medical strangers to this patient that comes into the emergency department, but we have to decide within
seconds, what we’re gonna do. Because they’re in extremis. Do I run a code, do I do a slow code, do I intubate but not
CPR, CPR but not intubate? There’s a million different
parts of the spectrum, most of which are kinda dumb ideas. But you have to make these decisions based on this very incomplete information. So you’ve now started to think, working… Tell me about this Institute
on HealthCare Directives and how this influenced you. – So the Institute on
HealthCare Directives is a hope that I can develop and formulate into many different health care systems. So UPMC could have an Institute
on HealthCare Directives, Ascension could have an Institute
on HealthCare Directives. It’s a concept. Now it’s my clinical practice where I do advanced care planning because I was getting frustrated with what was happening in my community, as far as people creating
documents, attorneys create them, a doctor might create them,
a nurse may create them, people that really aren’t
having good conversations and doing things correctly for patients. So I started my own practice to do this and that’s the institute. And through that institute,
we publish research, we work with nursing homes to teach how to do POLST documents, we work with nursing homes, how to have end-of-life
care conversations, we see patients in
conjunction with attorneys, estate and elder law attorneys, to make sure that their
plans are done with MIDEO, that we’ll talk about in a bit. But to do it in a way where we have a better way of
memorializing or documenting what they want and retrieving it in a way where we can actually make it come to life and save a life or let
someone die naturally. I get hit a lot with people think I’m a right to life advocate, I’m not. I don’t really care if
someone wants to live or die, and I don’t mean that facetiously, what I care about is doing right for that particular
patient and that family. To make sure that we either protect them and let them die naturally, or we resuscitate them,
’cause that’s their wish. – So the so-called AND, by
the way, allow natural death, is a very different way of
saying do not resuscitate. It’s a very different vibe. And I think it’s important that language, in this case, does actually matter. So in your mind, how
would a patient, ideally, then communicate their wishes
in a way that’s usable by us. – So we, I call it scripted video. In TRIAD VIII, we did a study, and if anyone takes
anything else from this, look at TRIAD VIII, all of you out there
who are doing research, publishing on POLST, publishing on living
wills, look at TRIAD VIII. It was a study that we essentially did, published in a Journal of Patient Safety, that showed clinical
scenarios with a living will, clinical scenarios with a POLST, and then those same
scenarios with a retrievable, scripted piece of video of a patient telling us what they want,
as far as their wishes. And that scripted video is gold. I kid you not. We can get as high as 99.6% accurate as far as to make someone understand if the patient’s a DNR, or to make them understand
if the patient’s a full code, even if they have a living will or POLST. So we can get very, very accurate now, as far as being able to
care for people, in a way. So essentially, I was looking for a way to produce a safeguard for patients. And I think MIDEO now
has become a safeguard that we can deploy because
education isn’t just the answer. There’s way too many people
involved in everybody’s care. There’s no requirements for me and you to look at a living will or a POLST and say, “Hey, you’re
competent to actually be able “to understand that document
and provide clinical care.” – Well it’s essentially, so MIDEO stands for My
Informed Decision on Video. And so it’s basically saying,
okay, mister or miss patient, tell us on video what your wishes are. And there’s a couple
advantages to that right. Because it’s coming
right out of their mouth, it’s not parsed through
a lawyer or family, it’s them saying it, and it’s, you probably structure it in
a way that it’s usable, right? – It’s very structured
and it’s done in a way, after an questionnaire as far as with a provider who’s trained, myself, you could train yourself, we could train any provider to do this. – [Zubin] I’m untrainable,
just understand that. – No, we’re all trainable, c’mon. (laughs) But we can literally do it in a way where, again, we produce a script. You got hypertension, right, you get a script for Lisinopril. This is a script for your advance care planning
has to develop more. It has to be able to develop to take care of me and
you when we’re healthy, that person who’s got moderate
complexity of illness, as well as that end-of-life patient. And you got many people
with their hands in the pot. You got palliative care
and in certain areas, palliative care is doing both
palliative care and hospice. You got hospice in certain areas that are doing both
palliative care and hospice. We’re telling people you can
go into hospice as a full code, to me, that’s just absolutely ridiculous. I think you set a patient up
for injury when you do that and misconception on
the health care system. But we script it in a way now, where it’s not just a
vague statement by you. Hey, don’t keep me alive
if I’m terminally ill. Well that’s a dangerous statement, because now I can look at that and say, hmm, you don’t look too good today, we’re gonna enact your document. Whereas, we give you a script, essentially making it so
that you identify yourself to joint commission identifiers, we essentially make it
so that you know how or we know how to treat you when you’re in a critically ill state, a witnessed cardiac arrest,
an unwitnessed cardiac arrest, and hey, who else you’re
supposed to contact if I hit these other parameters to make sure that you’re
getting the right direction, rather than making a guess. – So it includes your surrogate decision maker
that you’ve chosen. That’s very important. – And that’s an underutilized
person, by the way. – Underutilized and
poorly chosen many times. Oh, I’ll choose my wife or
my daughter or something. Well they’re so
emotionally attached to you they’re gonna change their
mind at the last minute, no matter what your wishes
are, one way or the other. – Great point. So that’s been something
that MIDEO’s been great with. We’ve been able to show Johnny who flies in from California
to see mom in Erie, who’s dying, who hasn’t
seen her in 20 years. We’ve been able to show him exactly what her wishes
are to resolve conflict. – So you can show the
family members the video and go, “Hey, look.” and you know what, okay,
I just had a thought. So, so much of the guilt
and shame of family members, they have this burden of
having to make this decision. Because, honestly, patient
and doctor dropped the ball, didn’t make the decision,
didn’t make it clear, didn’t talk to them, so now it’s on them. So Aunt Marge hasn’t
seen Johnny in 20 years, but now shows up for the first time and says, you know what,
we should do everything because you know, I… And there’s this guilt and shame. Now you show them this
video that Johnny made, saying listen Aunt
Marge, listen everybody, this is the deal, it’s scripted, this is what I want, this
is what I don’t want. That can absolutely decrease
suffering in the family. – Absolutely. And I have many patients
that have come to me and they’ve done that because their kids are so diverse, they don’t want their kids having to make that decision for them and fighting when it comes
to their end-of-life. – We put that in our Ain’t
the Way to Die video, and no one agrees in the family. The caregiver Kate wants her comfort care but and Claire lives so far away. That or guilt eats her like
a cancer so she answers, wait, I think you’ll wake. Mam, you ain’t even in the state. And that came from the
patient’s only heard wish, which was them saying at some point, I don’t wanna be a vegetable. What does that mean? – [Ferdinando] Exactly. – So now I’m really interested. Show me, I haven’t seen a demo of this. Show me how this works. – So today we use ID cards, but we could actually do things like ID cards or medallions and so on. But we script it in a way on the ID card based off of a principle called code. So your code status, your
position on organ donation, if you have any directives,
who your emergency contact is, and in that case, it’s your
health care agent, essentially. And then if you look at it, there’s IDs, there’s a picture on there. This is me right? So this is me as a John Doe. – Ferdinando Mirarchi,
code status, full code, date of birth, all the other stuff there. – This is my real one. So essentially, on it you have a QR code and that QR code is a very,
very simple piece of technology that’s able to bridge and
connect me and this ID card to produce something for you. – [Zubin] Point to the QR code. – The QR code is right here,
this little squiggly thing. – You see them all over the place . – You see them on plants, you see them, just to get quick bits of information. – Yep. – So today with this, in an ID card, you can essentially take
any smart phone, right, because everybody has them. – [Zubin] QR readers
built into the camera app. – Built into the camera. If I can remember my password. – Zoom in on his password guys. We just wanna…
(laughs) – You want access to my phone? – Yeah. – So like if I pull this up,
like if I show this here, you have a QR code. – [Zubin] Back it up a little
bit, so we’re in focus. There we go. – And then we’re gonna,
I don’t know if I’m gonna be able to do this like this. But we’re gonna go right
here and there it is. – [Zubin] Scanned it right away. – And in 10 seconds, not even 10 seconds, you now have something. – This is my informed decision on video. – Look over here. – Resuscitation choice is full code and the provision of CPR and ACLS, if my cardiac arrest is witnessed. If my cardiac arrest is unwitnessed, with a perceived prolonged
downtime and signs of death, then there is to be no trial of CPR. My date of birth is February 25, 1970 and this message has been validated by the Institute on HealthCare Directives. My mind is sound, as I
voluntarily record… – This is a script. – That’s a script. And it’s an evidence-based script, all produced from the TRIAD research that we’ve been able to figure out. And make it so that it becomes compliant, it becomes legal, it’s a
compliant medical order, it’s signed by a physician. – So I’m looking at this video, it’s got you, it’s got all
your stats on the left, it’s got some scrolling stuff
with contact information and it’s got you going through the script to make sure that you
don’t screw anything up and they don’t screw
anything up and it’s legit. – [Ferdinando] It’s legit. – So I’m in the ER,
they pull out that card, I scan it, or EMS pulls out the card. Because so often it’s
prehospital providers too, right, and they don’t know what to do. And so I can immediately see this. Now here’s my first question, HIPAA. I’m sure you’re getting
a lot of crap right? – No, absolutely not. So HIPAA protection. So we are HIPAA permissible, because it’s the same protection
as POLST document gets, it’s the same protection
as living wills get, in that this is life saving
or life ending information. So under the emergency
preparedness acts of HIPAA, it’s HIPAA permissible. – So that means that you
don’t have to go through all these weird secure servers
and all this other stuff? – Well we still do go through the servers, just because we’re very,
very protective about it and we wanna make sure that everybody’s information is protected. But simply just connecting the QR code to that video in a private link in a secure format actually
meets that requirement as well. – Wow so you have, effectively,
a HIPAA permissible, we won’t say HIPAA compliant,
we’ll say HIPAA permissible video-based app. And so here’s a question. To me, this is amazing. And our whole goal on the show is to try to shine lights on bright spots where things are actually working. You’re actually pointing out a problem that many nurses have messaged me about. This undertreatment, do not resuscitate meaning do not treat. It doesn’t. And they will complain that
doctors will walk away, nurses will walk away from
patients, like your father, who, that’s not their wish. So you have a solution now, that can actually solve this problem, based on actual clinical
data, in other words, your trials with TRIAD, you formed an organization to promote it, the Institute on HealthCare Directives, and then you have a company that actually is getting
it out into the world. Now here’s a question. So how do you make money
it, how do you buy it, how do you use it, how
can our people try it, who are you marketing it to? – Marketing to, I mean to prove concept, we essentially went to consumers, went to patients and so on. And at the same time,
trying to build relations with skilled nursing
facilities and payers alike. Now there’s no doubt that
this type of technology belongs with a payer-provider system. Deep down, I really don’t
think payers want to do bad. And I know doctors and
payers are always at odds. – I’ve talked to them,
they don’t wanna do bad, they wanna do the right thing, and it’s in their best
interests, financially, to actually prevent disease and so on. – Yep, and I think they want to do good, so ideally, it belongs within a system that can be a payer provider system to incentivize for completion and then essentially teach physicians and allow physicians to do this. Now I can do this and I get reimbursed by health care payers. Some of the best payers in the systems, I’ll get reimbursed anywhere from $200 to $330 to do what I do. And I wanna teach that, I wanna teach it to medical providers. – So teach me, what do you do
to get reimbursed like that. – So essentially we’re doctors right? – Purportedly, some
people don’t believe it. I constantly get these
messages on Facebook, are you, yeah right provider,
are you really a doctor? And I’m like, you know there’s
a thing called Dr. Google, where you could search that,
my credentials are online, but people don’t believe it
because I make the jokes. But anyways please, I’m a
little bit sensitive about that. So yes we are doctors, we are doctors. – As we all should be, it only cost us a half a
million dollars to get here. – [Zubin] I didn’t go to four years of evil medical school
to be called mister. So we’re all doctors. – It’s funny though too, most doctors really don’t
wanna be called doctor. At least that’s been my… Call me Fred. And literally, but you
see other people who just, they get that ego to them, right, they wanna be called doctor, and that’s not how real doctors are. Real doctors are doctors
who take care of people. – I’m so with you brother, I’m on that. That’s right, let’s do this. Oh, it burns. Because you’re an ER doc
and I’m a hospitalist, it’s like fire and ice. So you’re saying how you
get reimbursed for this, what you do as a doctor? – Yeah, it’s how you set your practice up. And we’re happy to teach this as we go to anyone who wants to consider doing it. It’s setting your practice up to be involved as a physician,
to medically evaluate, to medically re-stratify people. And we did a piece for ASRMA on this, the American Society of
Risk Managers Association, did a great webinar and
talked to people about this and how we can do this. But really the premise is,
people have to want to do it. So people seem to think that
this end-of-life conversation, people know or that they’re gonna either do it haphazardly and be
able to figure it out later. You have to find people who want to do it. And again, I think advance care planning, now that it gets reimbursed from Medicare and the payers are following, you have the ability now to
set, essentially, a subset up, where we do advance care planning, again, for the healthy patient,
for those with cancer, heart failure, COPD, ALS, and so on, and then the end-of-life people. Everybody’s not at end of life. You get a document, attorneys
tell people all the time, this document will only come into play if you’re terminally ill and there’s nothing they can do for you. Bull. Bull, you walk into a
hospital with a document, you walk into a hospital
living will, a POLST, people have a perception in their mind, they’re supposed to follow that document. Some of the best medical
editors in the world, when I was originally producing TRIAD, said that if that living will doesn’t make the patient a
DNR, I don’t know what does. Now you can have a living
will and still be a full code. It’s a matter of what people understand. And then as far as how to do it, we’ve developed a HIPAA compliant system to actually create these
and do all the data capture, demographic capture,
create the video scripts, educate the patient and so on in what I like to call
a facilitated approach. Facilitated events care planning, meaning we train people,
we credential them, we make sure they’re competent to actually do what they’re doing, and then essentially build
this into a practice model where you can see medical patients and have them come through
for their medical illness and do their advance care planning and even customize it to that illness. Because an ALS patient may
not want intubated later, they may want intubated early on, but they might not wanna be maintained on mechanical
ventilation, trached, pegged, and all the other
stuff that goes with it. It’s their decision, it’s not my decision, it’s their decision. It’s my right or my position is to educate and guide and
provide medical treatments. Some of those treatments
are for end-of-life, but it’s not my job as a physician, at least I don’t think it
is, to portray my opinions, my beliefs, based on those
moral biases that we all get, because we’ve taken care of so many people that
we’ve had to resuscitate that we probably shouldn’t
have resuscitated. – And it’s interesting because
the question would always be, well this is time-intensive
and training-intensive and how do we get paid for this again? – Yeah, so the timing, training,
it’s all based on timing. Advance care planning codes
now afford the ability to actually do this, do new
stuff, and even provide audits. Audits. Journal of Patient Safety just accepted a Triad XII paper we had, and it’ll come out in November. I can’t really speak too much about it, just because it’s in that protected zone in
copyright or whatever it is, but we did a study that
looked at existing DNR orders in a hospital and the
results were terrible. 40% of the time, patients had no idea they had
a DNR order in their records, 38% of the time didn’t even agree with it. They were just there
for chest pain rule-outs or a TIA workup or something and they had DNR orders in their record and it came from someone misunderstanding their
living will document. So again, we ask two questions all the time when you come in, how do you want treated in cardiac arrest and do you have a living will? And the way you answer those questions is how I teach my patients to navigate the health care
system that we can do for a lot of people now,
not just my patients. – So if I, as a health care professional, I’m doing this with your device, I can bill Medicare for
advance planning codes. – Not just Medicare,
you can bill any payer. – [Zubin] Commercial insurance. – Commercial insurance,
Medicare, the VA system, because they all follow
Medicare guidelines. – So this is a tool, actually… Because again, I believe
in what you’re doing and I want it to succeed and
the only way it’s gonna succeed is if the incentives align
for physicians to use it in a time-strapped world. So in your mind, so how would it work? A physician would, we would have to go through you guys to get credentialed? – We’d like them to, we’d like
them to use our technology. We’d like them to use the MIDEO app to provide the education. Apps are based and technology is based to try to bring
many to one, right? So that you can kinda
help control the masses and bring them all together and provide the same level of education, standardize the terms, to make sure people actually understand. So but we would like it so
that they would work with us, use our technology, so that we can provide the QA oversight to the whole system. You create a video, you wanna make sure a video
is appropriate, right? You don’t wanna hear about grandma doing crochet or anything like that. – If I can’t knit, I don’t want to live. – Well not just that, right, you can have a lot of inappropriate stuff that’s put in video. – If I can’t knit
underwear for young boys, I don’t want to live. – Exactly. – That came out wrong. (laughs) So I understand, so you would
want some standardization and also some evidence-based
protocols for doing this because otherwise it’ll be
just as bad as a living will. – Absolutely, and that’s
why you wanna make sure everything is done in a format, a controlled, educational format. Look, living wills are
there, POLST is there. POLST is a very powerful document, but it was really created
for that end-of-life patient. And when you try and throw
it out to the masses now, without appropriate
education, what happens? You get errors, right? And now we’re trying, you have systems actually trying to create their code set of systems that mirror up with the POLST statute in their state. Not the right thing to do. When you look at it, when you use a POLST, it’s very powerful in
that if they’re a DNR CMO, you can predict where they’re gonna die. You can predict that
location with high accuracy. With the DNR CMO again,
you can predict timing now. So now you got a very powerful document that can actually predict the
time that patient will die. So that’s why I say, we
have to be very careful in how we let this out to masses and not keep it within
that end-of-life spectrum. Because now you’re just applying an end-of-life spectrum to
the community as a whole, to the nation as a whole, not even the nation, but internationally. And now, you have a
perception POLST, end-of-life, this guy’s got a POLST,
he’s at end-of-life. – Wow, so again, it’s a
multifaceted thing about education, applying the right tools
to the right population, making sure it’s based on actual evidence and trial evidence, which you’re obtaining and have obtained, and they continue to publish in the Journal of Patient Safety. So in your ideal world, are
health systems picking this up? Are patients picking this up? Are providers, doctors,
nurses, nurse practitioners, PAs, people who talk to
patients about this stuff, are they doing this? Who’s the central choke point here? – So, I mean it all needs led by a system. And that’s my job this year, to make systems realize
that this is important for them to adopt and embrace. You can still do documents,
we’re not anti-document, we don’t say don’t do a
living will, don’t do a POLST. What we say is that you need clarifying
pieces to those documents, so that others understand and
that you don’t harm people and that you don’t get sued yourself. So, and the choke point
is gonna be that system, getting doctors to embrace. When I show doctors this, they like it. They like it because it’s informational, it’s directional, it’s guiding. When they hear about a living will they’re like, God dang it. – [Zubin] I hate looking at it. – Right, right. – POLSTs are a little more
direct, but like you say, they may be biased in the sense that they’re really towards the end-of-life and it’s a negative document. – Not so much the POLST being negative, more so the living will
being negatively expressive. POLSTs have order creation error, so if you have a living will that says, I don’t want mechanical ventilation, I don’t want CPR, I don’t want intubation, I don’t want antibiotics, all of a sudden, that becomes a DNR with
comfort measures only, to the untrained provider in a POLST. If you say, I want mechanical ventilation, but I don’t want CPR,
and I want antibiotics, then all of a sudden, that’s a DNR limited
treatment interventions, to that untrained provider
who’s creating a POLST. And when you look at it, and I’ve done this in
nursing homes myself now. The person creating the POLST, often is the admission
nurse or the social worker. And it’s terrible to put
them in that position because they’re not really
having the in-depth conversation for that patient and family. And then some provider comes by, a physician or a nurse practitioner or a PA and signs it off. – I’ve signed a million of them. – Right, and did you have
a conversation with them? – Often I did, often I did, because otherwise I wouldn’t sign it. – Well that’s good, that’s
great of you, that’s admirable. – Well I was just scared, again, it’s a legal thing too, like
I’m creating a legal document. If it’s wrong then, I’m
doing this person harm and I deserve legal retribution. You know what I mean? I’ve never said that out loud before. Let me never say that again. I never deserve legal… – See what happens when you put Philly and Jersey in the same room? – Philly and Jersey
together, two great tastes, that taste awful by themselves,
but together, booya! And so I’m talking to
health systems right now, I’m looking at the camera, so heath systems need to listen to this guy or some equivalent of him. I mean we’re not just
saying just use MIDEO, but I think MIDEO’s a great example. Even though it looks a little
bit like a hostage video. (laughs) So yes, I would like many things done and many things undone. (laughs) Here’s a question, how do
you prevent malfeasance, so it is it all in the training? In other words, like grandma really wants Junior’s
inheritance or vice versa. – [Ferdinando] It’s all in the training. – It’s all in the training. – Yeah and we, don’t get me wrong, that’s a very scripted
demonstrational video of my own and so on. We have people customize their videos. And it’s impressive when
they customize their videos and talk about their family quickly. Like we ask them, you can
customize this at the end, say something to your
family, give a final wish. One guy scared the crap out of me. I mean it was literally when the Indians got to the World Series, he came in the morning
of the World Series game and said if the Indians win,
now I can die, so now I’m here. I’m like holy crap, don’t say that! But his video is great in the end, and I can show it to you. In the end he was like, go Tribe! And those are memories for people. My first patient, I still
haven’t shut his video off, because every so often, I see it scanned. So it’s a memory that we wanna make sure is still around for that family. – Really a lot of different uses. I didn’t listen to your whole video, but what are your wishes then? What did you convey in your video? – So right now I’m a pretty
functional guy, right? So I’m a full code, especially if I have a witnessed cardiac arrest. If I’m in an unwitnessed cardiac arrest and you have no idea
how long I’ve been down and I look like I’m dead, I
want you to leave me alone. And at that point in time,
I’m comfortable with that. But if I’m in a witnessed cardiac arrest, that’s the person we should be treating. – [Zubin] Yeah. – Right, a witnessed cardiac arrest, for someone who’s very salvageable with good functionality prior, the guy who comes off the golf course who has a witnessed cardiac
arrest and has an MI, we shock that person, we get
them to the lab, they go home. – [Zubin] Yeah. – If we just simply stop it,
hey you have a living will or hey he didn’t want treated, that person’s gonna die and that person was
probably pretty salvageable. – So can I tell a quick story
that I still struggle with? Still kind of occasionally in the middle of the
night I think about this. And this was when I was a young attending. I had a 90 year old, very functional lady who got admitted for pneumonia. And I, my team admitted her
and then I sat down with her, literally, because my whole thing was I sit down with the patient
and spend some time. Because in those days
we had a lower census, we were almost like a
concierge hospital script. It was so great. – [Ferdinando] Not no more. (laughs) – Not no more. That’s probably the reason
I don’t do it there anymore. It was a really beautiful thing, because we actually had
shorter lengths of stay, because when we discharged patients, we sat down and went through it and made sure they didn’t bounce back. We called their PCP,
we had a conversation. So it was really a high-touch
care that actually, since medicine is
relationship-based, works. So I sat down with her and I said, “Okay, so it looks like
you’re pretty functional, “this pneumonia’s gonna get better, “you have good care at home, “what are your wishes if
something were to happen.” “Oh, I’ve already thought
about this quite a bit. “I had a husband who went through this, “I don’t ever want electric
shocks, I don’t ever want CPR.” “What if you would get
better and it was transient?” I was just talking to her. “No, absolutely not. “I feel like if something
like that happens “it’s the universe’s
way of saying enough.” So the next day she’s getting better I’m getting ready to discharge her, I’m sitting there talking about discharge instructions with her. No residents there,
because they’re losers. – He said that, not me! – Hey, I think the intern
had the day off actually. And so they had like some
covering team, whatever. And so I’m sitting there
and as I’m talking to her, she’s sitting in the chair and she goes, “I don’t feel so good.” And her eyes roll back and she slumps back in the
chair and she’s unconscious. And I’m like, “What the hell?” So I go and I feel her
pulse, there’s no pulse. So I grab the nearest nurse, pull her in, let’s grab an EKG lead and strap this on. The nurse says, “She’s DNR DNI.” And I said, “I know, I’m the
one who had that conversation, “but I wanna see what’s going on.” It was a systole and at this
point, I’m in that position where I’m like, I’m emotionally
attached to this woman. – [Ferdinando] You like her right? – I liked her. I’m emotionally attached to her, I’ve witnessed her cardiac
arrest, it’s in front of me, I know what to do about it,
like if I were running the code, I know exactly, okay this
is how we’re gonna do this. There is a chance that she’ll come back, because there’s… Is this a PE, is this
an electrolyte thing, is this some weird
tamponade, is this just, it could be a million things. But I know her primary problem
was pneumonia getting better, but she’s been hospitalized. So it’s like, at that point I was paralyzed for a good 30 seconds. – [Ferdinando] Scary. – Terrifying. And I had the same
thing, like but what if? And so you know what I did? I told the nurse, “Okay, get
ready to call a rapid response, “but don’t do it yet.” I grabbed the chart,
meaning I grabbed the COW, computer on wheels, which
we now have to call a WOW, and I looked up the family member’s name and this was a son who
was four states away and I called him right away. And I said, “I don’t wanna
stress you up right now, “but your mother was
admitted, as you know, “we called you earlier, “she’s just suffered a cardiac
arrest witnessed by me. “She told me very clearly
what her wishes are, “I wanna confirm with you,
that this is her thinking “and that, I know she
was in her right mind, “but I just want to run this by you.” And that was a bad idea, honestly, because if he would’ve said something– – [Ferdinando] You
probably would’ve acted. – I would’ve acted. But I was emotional, right. So he told me, he was
very upset, but he said, “If this was her wishes
and she told you that, “I’m gonna respect her wishes.” And we did and we let her die. And it was one of the
hardest things I had to do, I remember, and I still am very… I know I did the right thing,
but it felt so difficult. Now the thing is, if this were, if she had that app, right, then you have a documented document where the son sees it, the doctor sees it, and you just know, okay,
she was in her right mind. – [Ferdinando] And you
wouldn’t have been traumatized. – And I wouldn’t have been traumatized! Because I’m the only witness of that. Now I’m the treating physician,
I’m the attending physician, even the interns were like,
“You didn’t code her?” And I’m like, “You weren’t there “when I had the conversation with her.” So I think this is a way to, I think, bring a lot of guilt and
shame and other things, not just away from patients
and their families, but also from caregivers. So that’s why I’m really excited that you could come on the show and tell us what you’re doing. And I’m excited that a frontline clinician took it on himself to say
this happened to my father, this happened to my patients, I’m gonna do something about it. And we need more people like you. – Well thank you. – So thank you so much. Now what’s the call to action, what are we gonna tell people to do here? – So I think first and foremost, those that are in the world of research have to start looking
at the TRIAD research. There’s a body of research
there that’s unfunded, but unfortunately, many
don’t know about it because it takes about 17 to 20 years for any research, really, to
come to light in the market. But that research is there
and it’s very important as far as living wills and
POLSTS and keeping people safe. And there’s also tools in that research that allow people with checklists, as far as DNR verification
tools, it’s all very good. And again, it’s unbiased, it’s unfunded. The other thing I think people need to do is to learn about MIDEO. Go to mideocard.com, take
a look at the videos, take a look at the patient testimonials. One was a physician who actually got admitted to a hospital and had a nurse try and
slap a DNR bracelet on her. I mean it’s an amazing bit and it’s an amazing testimonial
that you have to hear because we do this, we do this
in health care all the time. – Spell it out for me, mideocards. – Mideocard.com. M-I-D-E-O-C-A-R-D.com. – And we’ll put that in the links. We’ll also put in links to your TRIAD data and any other links you send me we’ll put in the description on ZDoggMD.com, SoundCloud, et cetera. This is a podcast, it’s a YouTube thing, it’s a Facebook thing, but
it lives on ZDoggMD.com. And that’s a great resource for people to share with
their administration, with their health plans, with their emergency department directors, with their directors of nursing. I think this is important technology that can, not just save lives,
but save a lot of trauma. So thanks again Dr, Fred
Mirarchi, for coming on the show. – [Ferdinando] Thank you. – It’s really, this is
the kinda conversations that get me really fired up, because they treat a
pain point in our system that I think, until we address it, we’re not gonna be operating
at our highest game, we’re never gonna get to health 3.0. So thanks for coming on the show brother. – Thank you. – All right, we out! Peace.

48 thoughts on “What Does That DNR Really Mean? w/Dr. Fred Mirarchi | Incident Report 246

  1. Great discussion… it is a hard one to have and something not all teams are comfortable doing. Thanks for tackling another huge topic

  2. 1:35 Keyword: Collaborative The “big thing” we found in the renewable energy industry was that our disparate disciplines fostered collaboration between unlikely partners which lead to new innovation. When individual groups work together your voice (and bargaining position) becomes stronger… workers of the world unite and all that. One thing I am sure of, Fred Rogers knows y’all are being the best people you can be.

  3. Don’t name your girlfriend and fail to tell her. Have lots of stories about poorly done advance directives. Get social workers trained!

  4. Every nurse I've worked with knows "end of life" does not mean DNR. We educate patients and families r/t need for specific DNR orders and that they can be changed according to patient's wishes.

  5. So does a healthy person who travels a lot make these tools available in a fashion that if I’m in another city and something bad happens, that facility that doesn’t know me like my local doctor or hospital that has this info on file. Is there some sort of national clearinghouse house type of system that is checked for this sort of thing? if not, is something like that possible? Since most states have organ donor registries, does it make sense to try and get state governments to expand their systems to store an electronic copy of this type of information and share with medical facilities? I could see it as a voluntary service available for a small fee to cover the cost.

    Its not very practical to carry around that paperwork everywhere I go. I have tried carrying a usb thumb drive in my pocket with Adv. Dir. and a red cross drawn on it, but is someone treating me actually likely to find it? Am I going to remember to always have that on me? What if I am at the beach or swimming pool?

  6. Can attest to this that the words heard coming out of a residents mouth when told about a change in status was “well he’s a DNR”. To this day it still gets to me.

  7. This would be great to adapt for dementia patients, who may not want to be treated
    but can no longer express themselves.

  8. In the last few months, I've been to a hospital many times. I have only ONCE been asked if I had a living will and that was the one time I was doing outpatient testing. I was even admitted and when I got a copy of my records, they signed I did not have one and they didn't even ask. ALL because I am 22 and they ASSUME I do not have one. I do. It is not a DNR, but I made it specifically to not let my next of kin make my decisions.

  9. Guys, guys, simple solution. Open an in-house tattoo shop, offer all discharging patients a free, decorated to suit, small checklist tattoo. With appropriate discussion prior : ETT yes/no, ETT 2-3 days yes/no, Apache score >X treat/don't, plus socsec/Medicare numbers, whatev. Flowery but readable, universal location on the body.

  10. Could you please give us Muggles a description of the abbreviations and acronyms your guest is using? Thank you. 😀

  11. It’s sad when people don’t get the end of life they wanted, whether it’s due to healthcare provider lapses or other family members.

  12. Super scary. I am a physician myself and put myself down as FULL CODE here in CA. Anything less could be terminal when I have something short term which could be resolved. I will ONLY add a DNR when I KNOW I have a terminal illness in the advanced stages. Otherwise you may be kissing your a** goodbye after a cardiac arrhythmia, botched surgery, etc etc.

  13. Basically healthy adults should not sign ANYTHING other than POLST indicating every possible measure should be taken. Of course I want to be on a vent with a Foley and an ICP monitor if I got hit by a car and I am likely to recover!! It scares people unnecessarily to tell them about the big bad tubes and beeping machines. Those machines may allow you to attend your granddaughters wedding rather than your own FUNERAL!

  14. DNRs are always a tough thing, especially because patients don't always understand all of the options. My dad was explicit in wanting everything short of intubation done to keep him alive (his exact words were "I don't want to be soup on a machine with a tube that won't come out"), but when he was in his last week of life, we had him placed on BiPAP, cuz it wasn't intubation, but he couldn't stand it, but he was so hypoxic that his mind wasn't working properly, he didn't recognize me or my stepmother, didn't recognize his friends, and we finally had to take him off. It was the hardest thing to watch him literally suffocating to death. I still wonder, sometimes, if we could have let him die more comfortably if we had just forced him to stay on the machine. It was just so painful for him, and you could see it on his face. He was like a fish out of water. I wish assisted suicide had been an option in California, so that he didn't have to suffer.

  15. Thanks so much for this, I’m a big fan of your videos. This is the precise reason that I don’t have an advance Directive. I was a nurse for over 30 years and have seen and heard far to much to trust these things. I am going to be looking into the Mideo Card for myself as well as family members.

  16. Having multiple types of DNRs is the problem. DNR for cardiac arrest, but not for a car accident that has you on your death bed? DNRs were never meant to be broken down into multiple sub categories. DNR is a flat out do not resuscitate. If you don't want to be revived, get one! If you want ti live, don't get one. Having sub DNR categories where you want to be revived in this scenario, but another is just going to cause more problems. I'm almost 30 and have a flat out DNR. If I got resuscitated simply because some idiot didn't want to respect my wishes, or they wanted to claim the DNR said this or that, I'd sue the shit out of them. I have a DNR for a reason, as do many others. DNRs need to be fixed so it's a flat out DNR = no resuscitate, period. No stupid "I don't want to be revived for this, but I do for this."

  17. My mom, had a medical directive if she had complications after surgery, and she also had a DNR. The DNR, thankfully was respected. She was a type 1 diabetic, blind, blood pressure issues, and the melain sheaths were coming off of her nerves into her gut. She didn't have the third stint placed in her heart from the heart attack. So, she left via a second heart attack 7 yrs later.

  18. Thank you for this intelligent discussion with some well thought out and researched suggestions for dealing with this. I am an ER nurse, and yesterday had to deal with this for two terminal cancer patients. Thankfully, we have a good team that understands the nuances, most of the time. One of those terminal patients had not ever had the Advanced Directives conversation with family at all, and did not have a POLST, and we had to intubate when the patient went into respiratory arrest with no hope of the patient ever surviving extubation. The other was in respiratory failure, had a POLST, no family present, and the patient still verbalized forcefully no intubation, which agreed with the POLST. That patient was still treated aggressively for sepsis, which agreed with the POLST guidelines. The second scenario is how the system is supposed to work.

  19. LOL re: stereotype of ED docs as adrenaline junkies. One ED doc I worked with was a professional X Games skateboarder before he settled down into medical school.

  20. Great discussion. I have had patients who feared being kept alive on a ventilator signed a DNR became septic needed to be admitted to the unit and CNO came to me why are you putting a DNR in the unit? DNR does not mean do not treat.

  21. I have seen the DNR means “do not treat” attitude among health care professionals, even though I’ve been a nurse for a short time. I work in a rehab/nursing home facility and this can be the way of thinking for elderly or very sick patients. I don’t agree with this, and I have worked with many patients who ask about their options and what end of life is about. Thank you for bringing more attention to this issue and working towards fixing this rampant issue in the healthcare community.

  22. Providers ask and bring up code status prior to deciding tx quite often. I've never understood why this matters – DNR does not equal Hospice comfort care only, yet it does for some.

    My mind is blown everytime I see this, especially for treatable dx, like a complicated UTI to urosepsis… When talking to my parents and family, I've encouraged them NOT to sign a DNR for the Do Not Treat behaviors and instead have promised to honor their wishes when that time comes….

    I agree with not doing full code Hospice – it doesn't make sense and sets us all up for failure.

  23. I am grateful that the culture of my workplace is that we understand that DNR does NOT mean do not treat. I'm surprised and disgusted that is not the case everywhere. The video format to describe one's treatment goals/wishes is a great idea.

  24. What if that patient scenario at the start didn't want to be resuscitated by the cardiologist? It may have been her 3rd cardiac event and didn't want to go through it again and the cardiologist just ignored her wishes. The RN wouldn't have had the DNR in her hands for no reason.

    This doesn't seem like a "treatment" issue as it was a critical event and apparently she indicated she didn't want another round already.

    Did she have a specific details in that DNR?

  25. …and please STOP propagating the "stranger danger" trope for kids. It's a manufactured "crisis" by the sensational media. 98% of child abduction/abuse is by the father or a close male already known to the family. "Stranger Danger" is causing more societal harm than good by causing kids to be irrationally afraid of people who not only mean them no harm, but are more than likely good people to know.

  26. As for the last scenario of the elderly woman having cardiac arrest in front of you and you let her go, the alternative would have been worse.

    I've done end of life care and the last few days of life is not pretty be it via disease or natural causes. The cessation of food and drink, the dehydration, inability to swallow, the labored breathing…

    She just checked out probably not knowing what hit her — which is what shekind of told you she wanted.

    You did the right thing.

    I have my living will done and I can tell you, if I can avoid the last 3 days of my life and the trauma that causes carers and family, I will.

  27. How do we get this MIDEO on our pts. Charts??!! This is an amazing idea!!! This is the first time I've heard of this. Can we possibly scan it onto Epic??

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