Starting a difficult conversation
If a patient has a life-threatening condition, or is elderly with a range of complex health issues, medical staff have to decide what level of intervention to provide if the patient starts to deteriorate.
To help with this it’s useful to have a ‘ceiling of treatment’ documented in the patient’s file.
Cardiologist Dr Tammy Pegg says that not enough patients discuss their wishes for their end-of-life care. She says that even if there is a signed ‘not for cardiopulmonary resuscitation (CPR)’ or a ‘do not resuscitate (DNR)’ form in their notes, these don’t reflect the broader aspects of resuscitation.
“A deteriorating patient may be treated with intubation, artificial ventilation, dialysis, fluids, feeding and much more than just chest compressions and defibrillation,” Tammy says. “For some dying patients these actions may be risky and futile, and not give them the end they or their family would wish.”
To help focus the conversation on what clinicians are doing for a patient, rather than on what they are not, the ‘options for treatment and resuscitation’ (OtTeR) form was developed.
It replaces the ‘not for CPR’ and ‘DNR’ forms and incorporates the wider definition of resuscitation and other treatments offered in acute settings.
Any patient who is especially unwell or who has multiple health issues should have an OtTeR in place. However, Tammy encourages everyone to have a conversation with their family and healthcare providers about what end-of- life care they want, and then complete an advanced care plan (ACP), preferably before they come in to hospital. The OtTeR form sits alongside an ACP.
“We need to break the taboo around death; OtTeR and ACP documents help start the difficult conversations about what people want, and don’t want, at the end of their lives,” Tammy says.
OtTeR conversations can be complex. However, by using the serious illness conversation guide available to them, staff can help patients make treatment decisions which are in line with their wishes.
“Discussing their options is better than just asking patients if they want resuscitation,” says Tammy.
OtTeR is a dynamic document and able to be changed. It allows for a 24-hour period where staff and patients can reflect on the conversation and check they are still ok with the path they are on. The OtTeR form was co-designed with help from the NMH Consumer Council, Maori and chaplaincy representatives, and senior clinical staff. It has been trialled and unanimously endorsed by the NMH Clinical Governance Group.
Staff report that the introduction of OtTeR is enabling them to have important conversations and to reduce incidents of inappropriate treatment.
Page last updated: 26/06/2019