Table 3:

Participant Explanations for Variations in Policies and Practices related to TAVR Peri-procedural Code Status

A. Cancel TAVR “The expectation is that all patients are ‘full codes’ for the procedure and hospitalization. If the patient is refusing [to have the DNR removed], there is a discussion with them about it. If we know up front about it, there would be a discussion if the patient should even have the TAVR, and that came up yesterday. The patient then consented to have the DNR removed, and agreed to have CPR, temporary intubation, and medication. Or the TAVR would’ve been cancelled.” [Program 27]

B. Maintain DNR “For the most part, that means that these patients don’t want to be converted to ‘open’ under any circumstances. But a lot of them are OK if maybe they go hypotensive or brady, or they need compression or medication during the procedure… So, I guess we tailor it.“ [Program 6] “There are many older patients that have DNR, but they don’t have a terminal diagnosis. We’re not going to totally exclude them–it would be a DNR if something happened on the table. … I think if they have a DNR in place, and express no open chest, resuscitation, anything, then we respect that. We’re not going to resuscitate someone with DNR in place.” [Program 7] “No, it is not [reversed]. …Typically, they go in DNR. …About 20 patients in the past year.” [Program 8]

C. Negotiate meaning/purpose of DNR and code status “It’s not a ‘full code, no code’ world in our hospital, we have ‘no intubation/no meds’, …’meds/no intubation’, …’do intubation/no meds’ …we do everybody full code, and then if anything should happen during the procedure, we come out and speak to the family and ask how they want to proceed.” [Program 13] “I’ve found that …their understanding of [their DNR from 2013 is] if they are found down…and they are going to be brain dead, they don’t want to be resuscitated. Their biggest fear is being in a vegetative state and being on life support, unable to have quality of life. I don’t think they perceive DNR status as when you come in for elective or routine health care—I don’t think they think ‘it counts.’” [Program 45] “Because sometimes they are DNR for [an]other underlying condition that they wouldn’t want treatment for, separate from their [treatable] valve disorder.” [Program 46]

D. Rescind DNR and reinstate after the procedure Within 24–48 Hours “We still move forward … DNR is held while they’re in [procedure] and reactivated after [in PACU].” [Program 14] “I think [code status does not revert] in PACU, but once they’re admitted as an inpatient and up in the unit. …I’m sure a day goes by without anyone ‘hey, you’re full code’ and ‘no, I was DNR’. So, the nurse has to get the doctor to officially change it back.” [The patient might go up to the floor as full code if the provider doesn’t readdress it with the patient?] “Yes.” [Program 15] “Yes, [they’re asked to change to full code] for the first 24 to 28 hours post-procedure.” [What happened for patients who declined to do so?] “Then the goals-of-care discussion continues, and we can refer back to their primary care physician or cardiologist…” [Program 16] Duration of the hospital stay “[DNR is] reversible for the procedure. …What we found is that the patients that are DNR status, but good enough to go through the procedure, they generally have some other issues going on, so we try to address those issues and see if this is actually what they want – or do they feel like a burden to everybody? We discuss the whole psycho-social issues with them. [They remain full code] just during hospital stay.” [Program 28] Often [most] times…, patients remain full code throughout their hospitalization.” [Program 29] After 30 days “I think it’s more financial than anything, and that has to do with the Registry data, anything that has to do within that 30-days scope really is part of ‘the program hit’. We try to maintain that 30 days, because after that 30 days, it’s not an ‘at fault’ issue. If a patient gets into a car accident on day 28, that death gets blamed on the procedure. That’s the rationale.” [Program 47] “30 days–that’s just a number the team decided on…” [Program 46]

E. Documentation of DNR status after reinstatement “It is not in the computer – we just talk to [the patients] about it.” [Program 17] “I think the majority remain full code after the procedure, but there’s not clear documentation of that anywhere. It’s just a verbal understanding between the team and patient and family.” [Program 31] “I don’t believe it’s changed [in the record] …It’s on their record it’s DNR when they get out.” [Program 14] “I would say no, [not included in discharge summary] …No, [not readdressed at 30-day visit.]” [Program 27]

[square brackets] indicate interviewer comments/edits for clarity; program numbers identify speakers.