Do Not Resuscitate
December 11, 2007 9:47 PM Subscribe
Do Not Resuscitate. "For families facing the impending death of a loved one, few topics trigger more anguish than the Do Not Resuscitate order... There is little ambiguity in a DNR order: Emergency medical staff must withhold CPR and other life-reviving treatments if the patient's heart or breathing stops, allowing death." But, DNR orders aren't always cut-and-dried. There are many situations that complicate the medical professional's decision to comply. Related: Some people have opted to get a "D.N.R." tattoo, but others have wondered if it will hold up in court as a legal directive. [First link Via].
For the record, I would totally like to be resuscitated, please.
posted by notmydesk at 10:13 PM on December 11, 2007 [1 favorite]
posted by notmydesk at 10:13 PM on December 11, 2007 [1 favorite]
Not touching this one. Yet.
Yeah, that's how most families deal with DNR discussions. The tattoo link was interesting, amyms, thanks.
posted by mediareport at 10:13 PM on December 11, 2007 [1 favorite]
Yeah, that's how most families deal with DNR discussions. The tattoo link was interesting, amyms, thanks.
posted by mediareport at 10:13 PM on December 11, 2007 [1 favorite]
For the record, I would totally like to be resuscitated, please.
For the record, I would like you to be resuscitated, please.
I would also like you to be making more comics. :)
posted by Pope Guilty at 10:16 PM on December 11, 2007
For the record, I would like you to be resuscitated, please.
I would also like you to be making more comics. :)
posted by Pope Guilty at 10:16 PM on December 11, 2007
For instance, CPR has been shown to be have a 0% probability of success in the following clinical circumstances:
* Septic shock
* Acute stroke
* Metastatic cancer
* Severe pneumonia
The other ones I guess I can understand, but why doesn't CPR work with septic shock?
posted by Avenger at 10:17 PM on December 11, 2007 [1 favorite]
* Septic shock
* Acute stroke
* Metastatic cancer
* Severe pneumonia
The other ones I guess I can understand, but why doesn't CPR work with septic shock?
posted by Avenger at 10:17 PM on December 11, 2007 [1 favorite]
Oh, I love soup. If the only thing I could do was lay in bed all day and eat soup, I’d be happy. I wouldn’t even have to taste it. I could just take it through a tube. That would actually be better ’cause I wouldn’t even burn my mouth. Never let me die
posted by allen.spaulding at 10:24 PM on December 11, 2007 [5 favorites]
posted by allen.spaulding at 10:24 PM on December 11, 2007 [5 favorites]
I, dhammond, having just seen the movie The Other Side
Of Darkness, and not wanting to be in a coma like that lady in the movie,
hereby want Jerry Seinfeld to remove my life support, feeding machine,
lung-blower, etcetera, etcetera, etcetera.
posted by dhammond at 10:25 PM on December 11, 2007
Of Darkness, and not wanting to be in a coma like that lady in the movie,
hereby want Jerry Seinfeld to remove my life support, feeding machine,
lung-blower, etcetera, etcetera, etcetera.
posted by dhammond at 10:25 PM on December 11, 2007
in other clinical situations, survival from cpr is extremely limited...homebound lifestyle 4%...
i wasn't aware that "homebound lifestyle" had a precise medical definition. one thing i can tell you (with a gruesome first-hand story to back it up) is that if you're a homebound cat owner who loses consciousness, hits the floor and remains inert for long enough, your cat will dine on your eyeballs and tongue [/cat owner].
posted by bruce at 10:51 PM on December 11, 2007
i wasn't aware that "homebound lifestyle" had a precise medical definition. one thing i can tell you (with a gruesome first-hand story to back it up) is that if you're a homebound cat owner who loses consciousness, hits the floor and remains inert for long enough, your cat will dine on your eyeballs and tongue [/cat owner].
posted by bruce at 10:51 PM on December 11, 2007
Eek bruce, I didn't know that about cats. My husband is a police officer who has been the first-responder to many unattended deaths, and he's never encountered cat situations like you described (dogs yes, but cats, no).
posted by amyms at 10:56 PM on December 11, 2007
posted by amyms at 10:56 PM on December 11, 2007
Mod note: a few comments removed. please don't take this thred straight into LOLJEWS/FATTIES territory so early, go to metatalk for that
posted by jessamyn (staff) at 10:56 PM on December 11, 2007 [1 favorite]
posted by jessamyn (staff) at 10:56 PM on December 11, 2007 [1 favorite]
All I have to say is that my mother has been extremely clear about her wish for DNR orders. There is no question in my mind whatsoever that I will honor her wishes, and do everything in my power to ensure that her doctors honor those wishes. Whenever she winds up at the hospital (which is, unfortunately, has been not unusual these past few years), I always make this point clear to the doctors - even when the chance of it coming into play is absurdly remote.
Me, I would rather fight for every moment of life. Easy enough to say now when I am healthy, of course. Then again, I watched a dear friend fight (and eventually succumb to) cancer, and she truly changed my outlook on life forever by setting such an amazing example of strength and good cheer in the face of impending mortality. I can only hope that I can manage to muster up half as much dignity and courage if and when my time comes to face such a trial.
posted by Lokheed at 11:08 PM on December 11, 2007
Me, I would rather fight for every moment of life. Easy enough to say now when I am healthy, of course. Then again, I watched a dear friend fight (and eventually succumb to) cancer, and she truly changed my outlook on life forever by setting such an amazing example of strength and good cheer in the face of impending mortality. I can only hope that I can manage to muster up half as much dignity and courage if and when my time comes to face such a trial.
posted by Lokheed at 11:08 PM on December 11, 2007
best tune ever on testament's 'the gathering'...
who knew there was a crappy movie tie in
posted by jimjam at 12:24 AM on December 12, 2007
who knew there was a crappy movie tie in
posted by jimjam at 12:24 AM on December 12, 2007
lockheed: I don't mean to take away from your experience. I've faced a situation like this recently, and will likely face a new one soon. To me, the bravest thing you can do is to come to terms with the situation, and accept your fate? I think when the time comes to face death, I think it makes it easier for you and those around you to not let the fear ruin what you have left. And I think that it should be like that, for both sides.
What would make it worse, however, is to not honor a dying person's wishes. Even death row inmates are given that much consideration and dignity.
posted by ninjew at 12:26 AM on December 12, 2007
What would make it worse, however, is to not honor a dying person's wishes. Even death row inmates are given that much consideration and dignity.
posted by ninjew at 12:26 AM on December 12, 2007
Often, we admit elderly patients who have never thought about their chances. They still think from TV that CPR can always bring them back. Maybe they're in denial about their prognosis with stage IV cancer. A lot of frustrating cases simply revolve around their primary care doctor not discussing it with them, though they should.
So we admit these patients sometimes in extremis and we bring up DNR and living wills for the first time and there's an automatic No much of the time. Which may lead to a lot of heartache, difficulty, guilt, and other negative emotions, should the patient end up on mechanical ventilation, or in a coma from hypoxic brain injura secondary to prolonged CPR, or both.
Medicine is about helping people—but we are not in the business of supplanting the cycle of life and death. A DNR is a rational way to deal with the fact that, for a variety of reasons, if you go South, we will do all sorts of horrible things to you to keep you technically alive.
posted by adoarns at 1:24 AM on December 12, 2007
So we admit these patients sometimes in extremis and we bring up DNR and living wills for the first time and there's an automatic No much of the time. Which may lead to a lot of heartache, difficulty, guilt, and other negative emotions, should the patient end up on mechanical ventilation, or in a coma from hypoxic brain injura secondary to prolonged CPR, or both.
Medicine is about helping people—but we are not in the business of supplanting the cycle of life and death. A DNR is a rational way to deal with the fact that, for a variety of reasons, if you go South, we will do all sorts of horrible things to you to keep you technically alive.
posted by adoarns at 1:24 AM on December 12, 2007
Avenger:
It doesn't work with septic shock because the pathological condition is massive opening-up of the blood vessels due to chemicals elaborated by bacteria. This makes the blood pressure plummet, and the perfusion of organs by blood plummets with it. The heart does a better job pumping on its own anyway, and if it's not injured, no paltry pressure rises your pounding one someone's chest can muster will be able to raise the blood pressure sufficiently.
posted by adoarns at 1:29 AM on December 12, 2007 [1 favorite]
It doesn't work with septic shock because the pathological condition is massive opening-up of the blood vessels due to chemicals elaborated by bacteria. This makes the blood pressure plummet, and the perfusion of organs by blood plummets with it. The heart does a better job pumping on its own anyway, and if it's not injured, no paltry pressure rises your pounding one someone's chest can muster will be able to raise the blood pressure sufficiently.
posted by adoarns at 1:29 AM on December 12, 2007 [1 favorite]
if you go South, we will do all sorts of horrible things to you to keep you technically alive.
This explains Miami.
posted by hal9k at 1:54 AM on December 12, 2007 [8 favorites]
This explains Miami.
posted by hal9k at 1:54 AM on December 12, 2007 [8 favorites]
But the DNR won't necessarily do you any good in many circumstances. If you're in a care facility and everything is filed and on the record you might get something out of it, but in any random accident you're likely to be out of luck. At least that's my impression. I've never talked with any EMT's about this but I imagine that they aren't likely to be checking paperwork before working on someone. I just graduated from a police academy and our first aid instructor basically told us that in any situation where we will be called on to administer aid a DNR isn't going to be something we can worry about. Even a doctor in an ER won't take the time to check and reference everything. Likely your best bet is to have family members who know what you want so they can authorize or make requests of the people doing the actual resuscitation.
posted by ericales at 2:31 AM on December 12, 2007
posted by ericales at 2:31 AM on December 12, 2007
Don't Say the W word - filler piece in the British Medical Journal about a small misunderstanding involving DNR orders. In the spirit of full disclosure: this was written by my dad. Needless to say I'm very glad things turned out the way they did.
posted by Lotto at 3:57 AM on December 12, 2007
posted by Lotto at 3:57 AM on December 12, 2007
In case anyone was wondering - aforementioned dad is 50 years old, alive and well and also on warfarin for life.
posted by Lotto at 3:59 AM on December 12, 2007
posted by Lotto at 3:59 AM on December 12, 2007
In the case of zombification, I do not wish to have my brain destroyed or head removed.
posted by slimepuppy at 4:08 AM on December 12, 2007 [4 favorites]
posted by slimepuppy at 4:08 AM on December 12, 2007 [4 favorites]
I've never talked with any EMT's about this but I imagine that they aren't likely to be checking paperwork before working on someone. I just graduated from a police academy and our first aid instructor basically told us that in any situation where we will be called on to administer aid a DNR isn't going to be something we can worry about.
Good point, but those aren't really the circumstances where a DNR matters most, usually. Nearly all of us, at any age, assuming we're in otherwise manageable health, would surely want all heroic measures taken to save our lives in the kind of traumatic and catastrophic situations where EMTs or cops tend to show up (accidents, violent crime, etc.). Of course, there are those cases where a relative who disagrees with or doesn't know about a DNR might call an ambulance for a terminal loved one in extremis, so yeah, there are plenty of exceptions.
I think one of the important issues is not just establishing your wishes but selecting the best person -- often NOT an immediate relative -- to be your health care guardian and apply your advance directive if necessary. I had to make a DNR decision for a family member, and while I was firm and stuck to what I knew the patient wanted because she had outright told me earlier, I had a couple of doctors/nurses at the very last moment second-guessing (on the phone, for god's sake) and giving me the "Are you sure, are you sure? Maybe you should reconsider: if we don't do something in the next few minutes, it's curtains" treatment, and a medical ethicist on the other line saying, "Don't feel guilty; you're doing the right thing; they're just playing CYA." Oh, such fun.
So you can betcher ass that when I set up my will etc., I chose a friend who is nearby, knows exactly what I want, has the dispassionate true grit to follow through no matter who tries to push her around, and will be able to sleep at night afterward.
posted by FelliniBlank at 4:31 AM on December 12, 2007
Good point, but those aren't really the circumstances where a DNR matters most, usually. Nearly all of us, at any age, assuming we're in otherwise manageable health, would surely want all heroic measures taken to save our lives in the kind of traumatic and catastrophic situations where EMTs or cops tend to show up (accidents, violent crime, etc.). Of course, there are those cases where a relative who disagrees with or doesn't know about a DNR might call an ambulance for a terminal loved one in extremis, so yeah, there are plenty of exceptions.
I think one of the important issues is not just establishing your wishes but selecting the best person -- often NOT an immediate relative -- to be your health care guardian and apply your advance directive if necessary. I had to make a DNR decision for a family member, and while I was firm and stuck to what I knew the patient wanted because she had outright told me earlier, I had a couple of doctors/nurses at the very last moment second-guessing (on the phone, for god's sake) and giving me the "Are you sure, are you sure? Maybe you should reconsider: if we don't do something in the next few minutes, it's curtains" treatment, and a medical ethicist on the other line saying, "Don't feel guilty; you're doing the right thing; they're just playing CYA." Oh, such fun.
So you can betcher ass that when I set up my will etc., I chose a friend who is nearby, knows exactly what I want, has the dispassionate true grit to follow through no matter who tries to push her around, and will be able to sleep at night afterward.
posted by FelliniBlank at 4:31 AM on December 12, 2007
Oh, and it's not the paramedics and police I worry about; it's three hours or three days or weeks after you get to the ER, when it's pretty clear you're a crispy critter -- that's when somebody needs to stand up and be tough.
posted by FelliniBlank at 4:33 AM on December 12, 2007
posted by FelliniBlank at 4:33 AM on December 12, 2007
I've never talked with any EMT's about this but I imagine that they aren't likely to be checking paperwork before working on someone.
Here in NY, with patients of a certain age, we absolutely do. Unfortunately, much of the time the DNR is not immediately available or up to date, which puts us in the unenviable position of having to do CPR while the family gets really upset. NYS specifies that the DNR needs to be signed by a doctor every 90 days, and that only a valid, visible DNR is enough to make us stop resuscitation. Living wills and health care proxies might be good for doctors, but not for us. I personally have had to initiate CPR on a patient while the health care proxy screamed at me from across the room "She didn't want this!" If you can get them on a monitor and show that they have no electrical activity then a doc will usually sign off on discontinuing CPR, but sometimes it takes a while to get a medic with a monitor.
posted by brevator at 4:40 AM on December 12, 2007
Here in NY, with patients of a certain age, we absolutely do. Unfortunately, much of the time the DNR is not immediately available or up to date, which puts us in the unenviable position of having to do CPR while the family gets really upset. NYS specifies that the DNR needs to be signed by a doctor every 90 days, and that only a valid, visible DNR is enough to make us stop resuscitation. Living wills and health care proxies might be good for doctors, but not for us. I personally have had to initiate CPR on a patient while the health care proxy screamed at me from across the room "She didn't want this!" If you can get them on a monitor and show that they have no electrical activity then a doc will usually sign off on discontinuing CPR, but sometimes it takes a while to get a medic with a monitor.
posted by brevator at 4:40 AM on December 12, 2007
My mom was recently hospitalized for some breathing problems associated with a chemo she is on for her stage IV cancer. Now, notwithstanding her stage IV cancer, she's normally in pretty good shape-- walks a couple of miles a day, works part time (she's almost 65), etc. In the hospital the intern asked her in this really weird veiled way what her "wishes" were. It took her (and me, I was sitting right there) a while to figure out what the hell he was talking about. It made me think she needed a 'do recusitate, I have an excellent quality of life' form.
posted by miss tea at 4:41 AM on December 12, 2007 [1 favorite]
posted by miss tea at 4:41 AM on December 12, 2007 [1 favorite]
There are some folks who advocate changing DNR to AND which stands for "Allow Natural Death". The bad news is that DNR means nothing in an emergency situation where no one knows the patient's wishes. The good news is that the medical community has become much more willing to withdraw support.
I can't say enough good things about Hospice care. I have been fortunate enough to have three close relatives die at home with dignity, surrounded by family.
If you've never seen someone in an ICU on full life support with multi-system failure let me tell you it's not pretty. If it's a condition that can be reversed I say press on and do all you can. When treatment is futile, continuing support is cruel.
posted by whatever at 5:00 AM on December 12, 2007
I can't say enough good things about Hospice care. I have been fortunate enough to have three close relatives die at home with dignity, surrounded by family.
If you've never seen someone in an ICU on full life support with multi-system failure let me tell you it's not pretty. If it's a condition that can be reversed I say press on and do all you can. When treatment is futile, continuing support is cruel.
posted by whatever at 5:00 AM on December 12, 2007
EMTs definitely ask for and check DNR orders - at least where I am (NY/NJ). Especially after haven taken classes in both DNR Orders and Med/Legal for EMS.
posted by blaneyphoto at 5:06 AM on December 12, 2007
posted by blaneyphoto at 5:06 AM on December 12, 2007
You can watch families and patients up close struggling with this in Frederick Wiseman's 'Near Death' documentary.
One pattern is the families who want to do everything possible and never give up, until they get summoned in the middle of the night for false alarms a few times.
And if you don't want to get the plug pulled, consider the ancient guy who still keeps discussing Shakespeare sonnets, he's the only one of the dieing that the staff holds off on disconnecting.
posted by StickyCarpet at 5:23 AM on December 12, 2007
One pattern is the families who want to do everything possible and never give up, until they get summoned in the middle of the night for false alarms a few times.
And if you don't want to get the plug pulled, consider the ancient guy who still keeps discussing Shakespeare sonnets, he's the only one of the dieing that the staff holds off on disconnecting.
posted by StickyCarpet at 5:23 AM on December 12, 2007
In King County, a protocol implemented last year allows EMTs "the latitude to forgo resuscitation when they judge it to be "futile, inappropriate and inhumane" even when there is no official paperwork."
Here's a study that they did before they started using the new protocol county-wide. Over half of the withheld resuscitations came from verbal requests.
posted by amarynth at 5:31 AM on December 12, 2007
Here's a study that they did before they started using the new protocol county-wide. Over half of the withheld resuscitations came from verbal requests.
posted by amarynth at 5:31 AM on December 12, 2007
An RN of my acquantance once had a lady post surgery on a narcotic drip with a push button, and her family, not wishing to see her suffer, apparently was pushing the button while she was asleep. Uh, too asleep to push her own button. They snowed her and went home for the night. The RN is now looking at a patient with severly depressed respiratory function, and a DNR on file, who had no reason she couldn't live a normal life for another few decades.
She spent most of the shift running in every few minutes, shaking the patient and yelling at her, "Breathe, honey, breathe!"
posted by unrepentanthippie at 5:49 AM on December 12, 2007 [5 favorites]
She spent most of the shift running in every few minutes, shaking the patient and yelling at her, "Breathe, honey, breathe!"
posted by unrepentanthippie at 5:49 AM on December 12, 2007 [5 favorites]
There is a recent article in the Chicago Tribune regarding a DNR for a minor child in a local school district, and how the district had to decide how to handle DNRs.
posted by SuperSquirrel at 5:51 AM on December 12, 2007
posted by SuperSquirrel at 5:51 AM on December 12, 2007
I personally have had to initiate CPR on a patient while the health care proxy screamed at me from across the room "She didn't want this!"
Wow, that's horrible.
I've never talked with any EMT's about this but I imagine that they aren't likely to be checking paperwork before working on someone.
The EMTs' default assumption is understandably to resuscitate, but you can bet if a family member tells them there's a DNR they most definitely will be "checking paperwork before working on someone."
posted by mediareport at 6:04 AM on December 12, 2007
Wow, that's horrible.
I've never talked with any EMT's about this but I imagine that they aren't likely to be checking paperwork before working on someone.
The EMTs' default assumption is understandably to resuscitate, but you can bet if a family member tells them there's a DNR they most definitely will be "checking paperwork before working on someone."
posted by mediareport at 6:04 AM on December 12, 2007
My last little joke is going to be donating my cadaver to science, but with a 'Do Not Reanimate' tattoo on my chest.
posted by Ritchie at 6:29 AM on December 12, 2007 [5 favorites]
posted by Ritchie at 6:29 AM on December 12, 2007 [5 favorites]
My maternal grandfather had a do not resuscitate order. The nursing home knew it. The doctors knew it. My mom was there screaming to let him die and they did it any way. Why? I guess so he could live an additional 30-40 minutes in complete agony.
Now my paternal grandmother had the order as well. She was technically dead for several minutes. Saw the light and all. They brought her back. Boy was she pissed.
posted by milarepa at 6:46 AM on December 12, 2007 [1 favorite]
Now my paternal grandmother had the order as well. She was technically dead for several minutes. Saw the light and all. They brought her back. Boy was she pissed.
posted by milarepa at 6:46 AM on December 12, 2007 [1 favorite]
Miss Tea: ....the intern asked her in this weird veiled way what her "wishes" were...
I wonder if that intern was referencing Aging With Dignity's Five Wishes, a document that is accepted in 40 States (and generally honored in the others, including mine, Texas). If so, sorry you got a weird introduction to it. These conversations should not come off as weird or veiled to the patient and family. Many people live active full lives with late stages of cancer. But this is a conversation that should happen when people are not right around the corner from their death. At my hospital a social worker usually discusses this document with the patient and family early in cancer treatment so the discussion is already ongoing by the time the medical team needs to bring up a DNR document.
After an inservice at work about the Five Wishes document, I began having this discussion with my siblings, their families and our parents using this document as a guide. We're all healthy, but I'd feel better if this was clear between us before one of us is in particular state and needs those decisions made. It's an ongoing conversation. If you're interested in having this conversation with your loved ones the Five Wishes is a fairly easy way to start it.
On Preview these stories about DNR's not being honored are very sad. I my experience as a healthcare worker DNR's are at the front of the chart and DNR status of each patient is discussed at the beginning of each shift so everyone on the unit knows who is who. When I worked in an emergency room the EMT's sometimes brought in people knowing they had a DNR so they looked it up somehow - I don't know how.
posted by dog food sugar at 7:13 AM on December 12, 2007
I wonder if that intern was referencing Aging With Dignity's Five Wishes, a document that is accepted in 40 States (and generally honored in the others, including mine, Texas). If so, sorry you got a weird introduction to it. These conversations should not come off as weird or veiled to the patient and family. Many people live active full lives with late stages of cancer. But this is a conversation that should happen when people are not right around the corner from their death. At my hospital a social worker usually discusses this document with the patient and family early in cancer treatment so the discussion is already ongoing by the time the medical team needs to bring up a DNR document.
After an inservice at work about the Five Wishes document, I began having this discussion with my siblings, their families and our parents using this document as a guide. We're all healthy, but I'd feel better if this was clear between us before one of us is in particular state and needs those decisions made. It's an ongoing conversation. If you're interested in having this conversation with your loved ones the Five Wishes is a fairly easy way to start it.
On Preview these stories about DNR's not being honored are very sad. I my experience as a healthcare worker DNR's are at the front of the chart and DNR status of each patient is discussed at the beginning of each shift so everyone on the unit knows who is who. When I worked in an emergency room the EMT's sometimes brought in people knowing they had a DNR so they looked it up somehow - I don't know how.
posted by dog food sugar at 7:13 AM on December 12, 2007
The front page is all too personal today. My aunt had Alzheimers, and thankfully had made her wishes very clear to her children. She was acutely miserable in her nursing home, and was Not Resuscitated for a treatable illness. A hard choice for her children, but it was the choice she wanted.
My Mom died last week. She had a chronic illness that was killing her by inches. She was in hospice care (bless them, they are fantastic) living with my sister and several grandkids. She got pneumonia and we followed the DNR order, and did not send her to the hospital for IV antibiotics. It's not clear that it would have kept her alive, but if it had, she'd have gone to a nursing home, and that would have made her very unhappy, to the extent of her awareness. She died very peacefully in bed at home, with people who loved her nearby. She lived a full life, and died a peaceful death. If I can't live forever, I'd like to die in peace. When I'm very, very old.
Discussing the DNR should be part of discussing funeral and burial choices. It was good to have music, prayers and a poem all ready for the funeral, and to be able to tell our friends, "Mom chose that reading."
posted by theora55 at 7:49 AM on December 12, 2007
My Mom died last week. She had a chronic illness that was killing her by inches. She was in hospice care (bless them, they are fantastic) living with my sister and several grandkids. She got pneumonia and we followed the DNR order, and did not send her to the hospital for IV antibiotics. It's not clear that it would have kept her alive, but if it had, she'd have gone to a nursing home, and that would have made her very unhappy, to the extent of her awareness. She died very peacefully in bed at home, with people who loved her nearby. She lived a full life, and died a peaceful death. If I can't live forever, I'd like to die in peace. When I'm very, very old.
Discussing the DNR should be part of discussing funeral and burial choices. It was good to have music, prayers and a poem all ready for the funeral, and to be able to tell our friends, "Mom chose that reading."
posted by theora55 at 7:49 AM on December 12, 2007
Oh Theora55. My heart goes out to you and your family.
posted by dog food sugar at 8:31 AM on December 12, 2007
posted by dog food sugar at 8:31 AM on December 12, 2007
I've never talked with any EMT's about this but I imagine that they aren't likely to be checking paperwork before working on someone. I just graduated from a police academy and our first aid instructor basically told us that in any situation where we will be called on to administer aid a DNR isn't going to be something we can worry about.
I was a certified EMT-B in Massachusetts and we were told to always always administer CPR until a DNR order was presented. Thus, the importance if you really don't want to be resuscitated, of putting this an obvious place. Sure, the EMTs may have started working on you by the time someone sees your DNR order on the fridge, but once that's found, they'd stop in, well, a heartbeat.
I've polled my family extensively (and also my ex-husband for whom I am still legally responsible until the divorce is finalized) about what they want done in extreme situations, and also what they want done with their bodies. Everyone is still firmly on this mortal coil, and they all definitely want to be resuscitated. I'm just making sure I know now that yes, my relative really would like that feeding tube, thanks! And I've made it equally clear to everyone that if I am going to buy the farm, please, just let me kick the bucket in peace.
And then when I'm dead, I'd really, really like to be a crash test dummy. I'm nothing if not morbid. Morbid and PREPARED. Kind of like a zombie boyscout.
posted by grapefruitmoon at 8:53 AM on December 12, 2007
I was a certified EMT-B in Massachusetts and we were told to always always administer CPR until a DNR order was presented. Thus, the importance if you really don't want to be resuscitated, of putting this an obvious place. Sure, the EMTs may have started working on you by the time someone sees your DNR order on the fridge, but once that's found, they'd stop in, well, a heartbeat.
I've polled my family extensively (and also my ex-husband for whom I am still legally responsible until the divorce is finalized) about what they want done in extreme situations, and also what they want done with their bodies. Everyone is still firmly on this mortal coil, and they all definitely want to be resuscitated. I'm just making sure I know now that yes, my relative really would like that feeding tube, thanks! And I've made it equally clear to everyone that if I am going to buy the farm, please, just let me kick the bucket in peace.
And then when I'm dead, I'd really, really like to be a crash test dummy. I'm nothing if not morbid. Morbid and PREPARED. Kind of like a zombie boyscout.
posted by grapefruitmoon at 8:53 AM on December 12, 2007
I hate the idea of being kept on life support for years. The very idea of sucking up that much money for no useful reason makes my skin crawl.
Please, unplug me.
And in case of zombification, make certain to remove my head before you check to make sure I'm completely down for good. I am more resilient that I look and I'll bite your ass given half a chance.
posted by quin at 8:53 AM on December 12, 2007
Please, unplug me.
And in case of zombification, make certain to remove my head before you check to make sure I'm completely down for good. I am more resilient that I look and I'll bite your ass given half a chance.
posted by quin at 8:53 AM on December 12, 2007
A good friend just went through this and it has traumatized him beyond belief. They pulled the plug on their mother after the doctor told them should could be kept alive indefinitely through machines but wouldn't live otherwise. She stuck around for another 24 hours while her family waited - and argued whether or not to put her back on the machines. She never filled out a DNR and never discussed it so the family will never know if this was her wish. My friend is haunted by the fact that his last memory of his mother is her struggling for life that he could have given to her. Get yourself a living will - not for yourself - but for your family.
posted by any major dude at 9:03 AM on December 12, 2007
posted by any major dude at 9:03 AM on December 12, 2007
I'm an EMT and needless to say the complications involving DNRs/DNIs are many but luckily the issue is simplified for us. The law says that if you do not have the original DNR signed and dated properly directly in front of you, you cannot honor it (technically not even a photocopy is to be honored). I've lost count of the number of times I've been told "He's a DNR!" by family/friends/nursing home staff when we were beginning to work someone up. I demand the documentation and they say they don't have it so we put the pads on and start compressions. Patients are always "full code" status if the paperwork isn't on them in bracelet form or handed to us onscene -- this is remarkably common. I would say 8 out of 10 "He's a DNR" instances are worked if the patient codes in front of us. This counts even for "Do Not Resucitate" tattoos -- if it's not a legally valid signed DNR/DNI, we're going to work you. And for an elderly patient, CPR usually means breaking ribs. If you're not breaking ribs, you're doing it wrong. Something to keep in mind.
CPR can prolong your life but if you're in asystole or have PEA, you are essentially no longer living and no amount of CPR is going to bring you back to life. It always amazes me when a patient dies and the family are angry that neither we nor the ER staff could resucitate their 84 year old mother. We're carbon-based lifeforms who's life expectancy has more than tripled in recent times. It happens.
posted by inoculatedcities at 9:38 AM on December 12, 2007 [1 favorite]
CPR can prolong your life but if you're in asystole or have PEA, you are essentially no longer living and no amount of CPR is going to bring you back to life. It always amazes me when a patient dies and the family are angry that neither we nor the ER staff could resucitate their 84 year old mother. We're carbon-based lifeforms who's life expectancy has more than tripled in recent times. It happens.
posted by inoculatedcities at 9:38 AM on December 12, 2007 [1 favorite]
My last little joke is going to be donating my cadaver to science, but with a 'Do Not Reanimate' tattoo on my chest.
I'd rather donate my cadaver to mad science.
posted by Pope Guilty at 9:47 AM on December 12, 2007
I'd rather donate my cadaver to mad science.
posted by Pope Guilty at 9:47 AM on December 12, 2007
Same deal in this county. If there is no paperwork in front of us, we are to treat them as a 'full code' patient. If the DNR paperwork is there but isn't dated, or isn't signed, it's not valid. A valid signed DNR order overrides anything a family member says.
From our county prehospital care manual: "When appropriate DNR paperwork is not immediately available,
prehospital personnel shall begin resuscitative measures until the
code status is confirmed. If resuscitative efforts have been initiated
and a DNR Form, DNR medallion, or DNR order is subsequently
identified, these efforts shall be discontinued immediately."
F. DNR Order Not Confirmed
1. The patient is to receive full resuscitative measures.
G. DNR Order Confirmed
1. The patient is to receive supportive care only. Resuscitative
measures shall not be implemented, including:
a) Chest compressions
b) Defibrillation
c) Assisted ventilation
d) Intubation (Endotracheal or Dual Lumen)
e) Cardiotonic drugs (e.g. dopamine, epinephrine,
atropine, etc.)
H. Supportive care consists of, but is not limited to, the following:
1. Oxygen by nasal cannula or mask (no BVM or any device
that creates tidal volume)
2. Pain management (may contact the Base for an order for
patients such as those suffering from a terminal illness)
3. Intravenous hydration
I. Patients suffering from airway obstruction, major hemorrhage,
anaphylaxis, chest pain, etc. shall receive care as provided in
approved clinical care protocols except when the resuscitative
measures identified above are required.
--
So, it means "Do Not Resuscitate" and not "Do Not Respond."
Here is our county protocol for DNRs.
posted by drstein at 10:15 AM on December 12, 2007
From our county prehospital care manual: "When appropriate DNR paperwork is not immediately available,
prehospital personnel shall begin resuscitative measures until the
code status is confirmed. If resuscitative efforts have been initiated
and a DNR Form, DNR medallion, or DNR order is subsequently
identified, these efforts shall be discontinued immediately."
F. DNR Order Not Confirmed
1. The patient is to receive full resuscitative measures.
G. DNR Order Confirmed
1. The patient is to receive supportive care only. Resuscitative
measures shall not be implemented, including:
a) Chest compressions
b) Defibrillation
c) Assisted ventilation
d) Intubation (Endotracheal or Dual Lumen)
e) Cardiotonic drugs (e.g. dopamine, epinephrine,
atropine, etc.)
H. Supportive care consists of, but is not limited to, the following:
1. Oxygen by nasal cannula or mask (no BVM or any device
that creates tidal volume)
2. Pain management (may contact the Base for an order for
patients such as those suffering from a terminal illness)
3. Intravenous hydration
I. Patients suffering from airway obstruction, major hemorrhage,
anaphylaxis, chest pain, etc. shall receive care as provided in
approved clinical care protocols except when the resuscitative
measures identified above are required.
--
So, it means "Do Not Resuscitate" and not "Do Not Respond."
Here is our county protocol for DNRs.
posted by drstein at 10:15 AM on December 12, 2007
any major dude, I've lived through the flip side of what your friend suffered.
My father had alzheimer's. Then he suffered a series of small strokes that took away his ability to move or speak. The nursing home told us he could be moved to a hospital and given whatever support was necessary to keep him alive, or that he could stay at the home where we could visit him whenever we wanted, where he knew the people who were caring for him, and that they'd do everything they possibly could for him.
We chose to let him stay at the home. He slowly slipped away over the next five days, and watching that happen on a daily basis was the hardest, most distressing thing I've ever done. But I'm glad we didn't have his life artificially extended because at the end he was in no pain, we were with him the last time he was conscious, and he slipped away quietly in his sleep.
It still hurts more than a year later, but I'm still glad we made that decision because the alzheimer's and the strokes had taken everything away from him.
posted by arc at 10:22 AM on December 12, 2007 [1 favorite]
My father had alzheimer's. Then he suffered a series of small strokes that took away his ability to move or speak. The nursing home told us he could be moved to a hospital and given whatever support was necessary to keep him alive, or that he could stay at the home where we could visit him whenever we wanted, where he knew the people who were caring for him, and that they'd do everything they possibly could for him.
We chose to let him stay at the home. He slowly slipped away over the next five days, and watching that happen on a daily basis was the hardest, most distressing thing I've ever done. But I'm glad we didn't have his life artificially extended because at the end he was in no pain, we were with him the last time he was conscious, and he slipped away quietly in his sleep.
It still hurts more than a year later, but I'm still glad we made that decision because the alzheimer's and the strokes had taken everything away from him.
posted by arc at 10:22 AM on December 12, 2007 [1 favorite]
Condolences, arc, but although that's a very hard thing to do, you were also afforded a great privilege: to be there with your father and share the last important experience of his life. How comforting that must have been for him regardless of his level of "awareness."
posted by FelliniBlank at 11:42 AM on December 12, 2007
posted by FelliniBlank at 11:42 AM on December 12, 2007
When my grandmother had a stroke, she made sure she brought her DNR forms with her to the hospital. This probably wasted 10 minutes of time that she could have been in a doctor's care.
Fortunately in this case it wasn't an issue, but it could have been.
posted by Pants! at 12:33 PM on December 12, 2007
Fortunately in this case it wasn't an issue, but it could have been.
posted by Pants! at 12:33 PM on December 12, 2007
That 5 Wishes document is very interesting, dog food sugar. Happily although being Stage IV my mom is not there yet. Hopefully we won't be there soon, but when we are, I will bring that up with my mom and her oncologist. I think that was the odd thing about the conversation-- my mom has a team of doctors led by her oncologist, and it was the ER intern who brought the DNR up.
My condolences to Theora and arc.
posted by miss tea at 12:51 PM on December 12, 2007
My condolences to Theora and arc.
posted by miss tea at 12:51 PM on December 12, 2007
My maternal grandfather had a do not resuscitate order. The nursing home knew it. The doctors knew it. My mom was there screaming to let him die and they did it any way. Why? I guess so he could live an additional 30-40 minutes in complete agony.
That sucks, but a lot of people would consider it worse if the docs listened to some family member who had misunderstood / projected a little (whatever) and let someone die who other family members later claimed had actually wanted to live. That's why the signed & dated official document is important...
It's a weird moral conundrum since we now take the technologically advanced scenario as the default.
posted by mdn at 3:39 PM on December 12, 2007
That sucks, but a lot of people would consider it worse if the docs listened to some family member who had misunderstood / projected a little (whatever) and let someone die who other family members later claimed had actually wanted to live. That's why the signed & dated official document is important...
It's a weird moral conundrum since we now take the technologically advanced scenario as the default.
posted by mdn at 3:39 PM on December 12, 2007
DNR orders are one of the very few reasons I'd be willing to have some kind of chip implanted under my skin, a la those pet finder devices.
I'm not a big bracelet fan, I have no idea where the forms I filled out *are* (and I highly doubt they'd be valid, not being signed by a witness, let alone a doctor), and I really hate the idea of artificially prolonging my life. Unfortunately, my family does not feel the same way, thus no chance of anyone saying anything there.
So, a chip under my skin in order to get my feelings on the matter across really sounds appealing...
posted by librarylis at 12:59 AM on December 13, 2007
I'm not a big bracelet fan, I have no idea where the forms I filled out *are* (and I highly doubt they'd be valid, not being signed by a witness, let alone a doctor), and I really hate the idea of artificially prolonging my life. Unfortunately, my family does not feel the same way, thus no chance of anyone saying anything there.
So, a chip under my skin in order to get my feelings on the matter across really sounds appealing...
posted by librarylis at 12:59 AM on December 13, 2007
What a great topic for a post! This is an issue that I have to deal with from time to time, and the more people discuss and think about these things ahead of time, the easier these decisions are. For a little perspective; it is important to remember that there are relatively few situations where recovery from full-blown cardiopulmonary arrest is successful; in this 30-year series, roughly 85% of patients who underwent CPR did not survive to discharge. This success rate is certainly high enough to make CPR worthwhile, but the majority of patients who require resuscitation die anyway..
A situation that is often not thought of until the last minute is what happens when a DNR patient is brought to the operating room. Some of the standard procedures of general anesthesia overlap with those of resuscitation (the father of CPR was an anesthesiologist, in fact), and there are a lot of potential events in the OR that can be fatal without some sort of resuscitation but with even a brief resuscitation full recovery is quite likely. Do you suspend the DNR order for the duration of surgery? For the duration of surgery and recovery? Do you let a patient die when you know a few minutes of artificial ventilation will allow them to completely recover to their previous level of health? Obviously there is no one size fits all policy for these situations; the American Society of Anesthesiologists in cooperation with the American College of Surgeons have developed guidelines for dealing with this situation. (More here.)
Unfortunately, without the backing of the patient's family, wishes about withholding treatments are often ignored. A case in point is Dr. Michael DeBakey. Evidently he developed an aortic aneurysm but declined surgery, as he was well into his nineties and it is a big, risky operation to repair these. Eventually the aneurysm began to leak and he slipped into unconsciousness, at which point his family and surgical colleagues decided to proceed with the operation. A big dustup followed, with the hospital's anesthesiologists refusing to do the case, the surgeons finding outside anesthesiologists, the hospital refusing to grant them privileges, and I am guessing a lot of tempers flaring, accusations being thrown, and professional relationships ruined. In the end he got the surgery and did well; I can only assume he is glad he did. Even so, this case illustrates how difficult it can be to resolve these dillemmas in real life.
posted by TedW at 6:14 AM on December 13, 2007 [1 favorite]
A situation that is often not thought of until the last minute is what happens when a DNR patient is brought to the operating room. Some of the standard procedures of general anesthesia overlap with those of resuscitation (the father of CPR was an anesthesiologist, in fact), and there are a lot of potential events in the OR that can be fatal without some sort of resuscitation but with even a brief resuscitation full recovery is quite likely. Do you suspend the DNR order for the duration of surgery? For the duration of surgery and recovery? Do you let a patient die when you know a few minutes of artificial ventilation will allow them to completely recover to their previous level of health? Obviously there is no one size fits all policy for these situations; the American Society of Anesthesiologists in cooperation with the American College of Surgeons have developed guidelines for dealing with this situation. (More here.)
Unfortunately, without the backing of the patient's family, wishes about withholding treatments are often ignored. A case in point is Dr. Michael DeBakey. Evidently he developed an aortic aneurysm but declined surgery, as he was well into his nineties and it is a big, risky operation to repair these. Eventually the aneurysm began to leak and he slipped into unconsciousness, at which point his family and surgical colleagues decided to proceed with the operation. A big dustup followed, with the hospital's anesthesiologists refusing to do the case, the surgeons finding outside anesthesiologists, the hospital refusing to grant them privileges, and I am guessing a lot of tempers flaring, accusations being thrown, and professional relationships ruined. In the end he got the surgery and did well; I can only assume he is glad he did. Even so, this case illustrates how difficult it can be to resolve these dillemmas in real life.
posted by TedW at 6:14 AM on December 13, 2007 [1 favorite]
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posted by Autarky at 10:01 PM on December 11, 2007