Friday, August 23, 2013

Do Not Resuscitate Orders - Part Two

Decisions to not perform CPR are controversial.  CPR is intended to restart the heart which has been suddenly stopped as a result of drowning or a minor heart attack.  It is intended to save a person who is otherwise pretty healthy.  It has become, however, one on the most widely performed medical procedures even when it is futile.  DNR orders prevent this procedure, which is often considered the standard of care, from being performed.

Why would you withhold CPR if you can restart a patient's heart or breathing?  


Survival rates of CPR attempts are not what we might believe.  Less than 1 in 5 elderly patients who had a need for CPR while in the hospital survived to be discharged.  Rates are even lower for those with complicating factors such as cancer or age related fragility.

Why would you not attempt resuscitation if you can give the patient more time?

The patient may not want to be revived.  Period.  Full Stop.

The patient may not be revived to the same functioning level as prior to the event.  Bones may be broken.  Internal organs may be damaged.  One quarter to half of patients who survive CPR may be left with neurological damage due to the loss of oxygen to the brain.

Who has to follow a DNR?


In general, if it is a durable DNR, pretty much anyone who may normally administer CPR must refrain from it if they are presented with the DNR orders.  This includes medical staff as well as care providers in home, day hab programs, or respite providers out in public.  The laws around this may vary from jurisdiction to jurisdiction so please familiarize yourself with the laws in your area if you decide a DNR is needed.  Additionally, please make sure you have plenty of copies to share with any care providers who are involved.

Do we have to have this discussion?  

Yes.  We do have to discuss DNR orders.  We have to discuss them early and repeatedly because we need to know where each of us stands on the topic in case we are ever called upon to answer for a loved one who cannot answer for themselves.

This leads me to DNR orders and Lyn.  Mom has already secured durable EMS DNR orders on my sister.  Mom is going to discuss a physician's DNR for Lyn with her physician soon.  I fully support these decisions.

Lyn has a terminal disease for which there is no cure.  As her disease progresses over the coming years, Lyn's physical condition is going to decline just as much as her brain declines.  If her heart should stop, what would we be bringing her back to experience?  Would CPR even be successful for her or would that be a false hope based off of a procedure which is popular on TV because it is showy?  Would she be in more pain, have more brain damage, or be in a vegetative state?  How is any of that a benefit to her?  Should we keep her physically alive just because we are not ready to let her die?  Again, how is that of benefit to her?

We have been discussing this for several months and are agreed.  Lyn's Alzhiemer's diagnosis and the questions we asked in the above paragraph were really what guided our decisions.  However, when we decided to write this two-part topic, I dug into the topic of CPR a bit more, researched and even spoke with an experienced ICU nurse about CPR and its results.  I can honestly say that I was surprised at what I learned.  I previously thought it was more successful than it is.  A dear friend from college is alive today because of the CPR performed when his heart stopped.  Unlike Lyn, he was a good candidate for the procedure.  He is young and doesn't have a terminal disease.  Lyn is young but does have a terminal disease.  That is a significant difference.

Comfort care is appropriate in Lyn's case when the time comes that her heart stops.  If this happens at day hab or while she is with a respite provider, they must honor the DNR orders according to NM law.   As a result of these decisions, we will soon be updating Lyn's medical alert bracelet to include a DNR notation.  That way, if she's out and the papers are not at hand, at least it is noted on the bracelet which is never off her wrist.


Additional Information:
Ethics in Medicine - University of Washington School of Medicine: Do Not Resuscitate Orders 

2 comments:

  1. I did not realize how unsuccessful CPR could be until my recent heart attack. In my case, they had five minutes to revive me, and chances were 50-50 at best. It took me a few days to even accept that it had happened.

    I have talked about burial arrangements/funeral stuff with my family, but there hasn't been talk of DNR matters because we're all reasonably healthy (although all of my siblings and I have had cardiac issues in the last two years). I think all families should discuss these things, just as you say, terminal illness or not, so that issues can be discussed with a clear head.

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    Replies
    1. I am glad there were people around you who knew how to perform CPR when you had a heart attack and I am deeply glad you survived.

      I thought it was interesting that when this posted yesterday, there was a case in the news of prolonged CPR saving a young man's life. Here is the link:

      http://www.nbcnews.com/health/dead-mans-recovery-shows-why-prolonged-cpr-works-6C10980325

      You're right to have the discussions on quality of life, end of life and desired care decisions with your family now, no matter how uncomfortable. May they help you all understand your options better.

      Thank you for the comment, AZThespos.

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