Allow Natural Death vs DNR

parrispa@musc.eduparrispa@musc.edu
in CDI Talk Archive
One of our physicians would like to do away with the DNR wording and substitue 'Allow Natural Death' instead.
I would like to hear if any one else is having a problem with this issue.
Thanks,
Pam

Comments

  • angelisa.romanelloangelisa.romanello
    edited May 2016
    Hi Pam,
    I have seen "allow natural death" comfort measures only.
    Lisa
  • parrispa@musc.eduparrispa@musc.edu
    edited May 2016
    That would be my thinking also.
    pam

    Pamela Parris, RN
    Clinical Documentation Integrity
    MUSC MAIN HOSPITAL
    Charleston, South Carolina 29425
    Pager: 12295 (843) 792-3442


    “Patriotism is easy to understand in America; it means looking out for yourself by looking out for your country" Calvin Coolidge
  • Unknown
    edited May 2016
    I personally love this terminology "allow natural death" much better than DNR status.
    This seems more dignified for the patient and family.

    Tina Simpson, BSN, RN, CCDS
    Batesville, AR
  • parrispa@musc.eduparrispa@musc.edu
    edited May 2016
    Yes, it sounds better, but does it have enough specificity as to how the patient will or will not be treated?
    pam

    Pamela Parris, RN
    Clinical Documentation Integrity
    MUSC MAIN HOSPITAL
    Charleston, South Carolina 29425
    Pager: 12295 (843) 792-3442


    “Patriotism is easy to understand in America; it means looking out for yourself by looking out for your country" Calvin Coolidge
  • Unknown
    edited May 2016
    Baptist has used that verbiage for a very long time- Allow natural death
    thanks Jamie Dugan BMC Jacksonville, florida
  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited May 2016
    With CPOE, there will likely still be an "order" for "DNR" ... helps when looking to capture the v-code (which at least for the UHC mortality model is a new significant variable with the 2012 model just released a few months ago).

    Don
  • nieke.oglesbynieke.oglesby
    edited May 2016
    Our hospital has used this term "Allow Natural Death" (AND) for several
    years. The nurses have to remind physicians in the beginning to use the
    AND terms vs DNR. Now the physicians use "AND" when documenting DNR in
    the EMR.
    Nieke Oglesby, RN, BSN
    Baptist Health System, Jacksonville, FL.
  • ddouthitddouthit
    edited May 2016
    Would "Allow Natural Death" be synonymous with DNR and coded to V49.86?

    Dorie
  • parrispa@musc.eduparrispa@musc.edu
    This is where the physician is heading, to use the AND for DNR.
    pam

    Pamela Parris, RN
    Clinical Documentation Integrity
    MUSC MAIN HOSPITAL
    Charleston, South Carolina 29425
    Pager: 12295 (843) 792-3442


    "Patriotism is easy to understand in America; it means looking out for yourself by looking out for your country" Calvin Coolidge


    Confidentiality Notice:
  • npaeanpaea
    edited May 2016
    I agree, Tina.
  • nieke.oglesbynieke.oglesby
    edited May 2016
    I do, as well. It sounds as though we are allowing nature to take its
    course. DNR just sounded so harsh as to say "don't do anything, let the
    patient die." Nieke.
  • parrispa@musc.eduparrispa@musc.edu
    edited May 2016
    I do agree that is does sound better,
    pam

    Pamela Parris, RN
    Clinical Documentation Integrity
    MUSC MAIN HOSPITAL
    Charleston, South Carolina 29425
    Pager: 12295 (843) 792-3442


    "Patriotism is easy to understand in America; it means looking out for yourself by looking out for your country" Calvin Coolidge
  • kmckaigkmckaig
    edited May 2016
    I concur.


    Karen McKaig, BSN, RN, CCM, CPUR, CCDS
    Case Manager
    Clinical Documentation Specialist
    Baxter Regional Medical Center
    Mountain Home, AR 72653
    870-508-1499
    kmckaig@baxterregional.org
  • angelisa.romanelloangelisa.romanello
    edited May 2016
    Don is correct about the CPOE.
    Also, I wonder if this is a concept which may vary from state to state. I believe you may be discussing a legal issue here.
    Lisa
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Don,
    I was going to say the same. It seems there would be a 'DNR' order still. Correct?

    Can you explain what you are referencing as far as the "HC mortality model"? What is the impact here?

    Thanks!

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited May 2016
    UHC -- University Healthsystem Consortium -- is collaborative organization where about 115 of the academic medical centers share data, information, best practices etc.

    Member organizations share various data (including the administrative/coding data set). UHC has a mortality model that provides an expected or risk of mortality developed by rigorous statistical modelling / study -- for each base DRG.

    As a member, one can down load the models, see exactly what goes into each model & variable, compare / contrast one's own performance in multiple slices (there is an online data base that allows manipulation/reporting), the ability to discover what most often increases expected mortality (for example, 53% of the models are influenced by POA Y AKI/ATN/etc, 31% by DNR), and can apply the appropriate model to an individual case.

    DNR was added to the models in the most recent version released a couple of months ago. It wasn't something often coded here ... however, now it is coded consistently & we are going back to update coding profiles where DNR's were ordered (back to that comparative elements of the UHC data base and trying to make sure that there is accurate reflection of how sick our patients are).

    My comment on the order -- if there is concern whether "AND" would be coded, one could hopefully still fall back to the order to ensure the capture of that particular data element.

    Don
  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited May 2016
    To take briefly a bit further --

    We have a several prong attack on how we are addressing mortality.

    First, having abstracted the 20 most common variables and identify the diagnosis for each variable, we (CDI) routinely query with concurrent reviews to establish those diagnosis when not documented (shot gun approach) (coding has the same information and will pursue much of the same diagnosis post-discharge). Some of these diagnosis are NOT CC/MCC & include PVD, dehydration, pulmonary htn, underweight ...

    Second, we screen all expired cases -- if not at an expected level for the appropriate model, we conduct an exhaustive coding and CDI review.

    Third, we are using this knowledge with much of our messaging with physicians -- supporting the importance of documentation, our work, fostering engagement, monthly education flyers, working directly with quality & various service lines (who are paying growing attention to mortality index & profiling) ...

    Don

    Donald A. Butler, RN, BSN
    Manager, Clinical Documentation
    Vidant Medical Center, Greenville NC
    DButler@vidanthealth.com ( mailto:mDButler@vidanthealth.com )
  • dloefflerdloeffler
    edited May 2016
    Don,

    Does code V49.86 for DNR have to be captured in the top 9 codes of the data set? Our consultant is telling us we need to capture palliative care code V66.7 in the top 9 codes reported. I believe CMS is accepting the top 25 codes and I am curious how many diagnosis codes actually are used for mortality and risk reporting.

    Debbie Loeffler, RHIA
  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited May 2016
    As I recall, there are only a certain number of diagnosis codes, and a certain number of procedure codes that are transferred through to CMS. So, if an organization captures 35 diagnosis codes, CMS only accepts the first X (used to be 9, though I believe you are correct CMS is now accepting more codes).

    I'd ask your consultant directly what is the current number of codes that CMS is accepting. My (fuzzy) memory is suggesting that changed only a couple of years ago.

    I don't know for a fact, but I would suspect that whatever engine is used to calculate ROM, all available reported codes are used -- from a data integrity point of view, that would have to be the case.

    Don
  • dloefflerdloeffler
    edited May 2016
    Thank you. I appreciate your expertise and willingness to share!
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