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Thursday, September 10, 2015

DNR

I recently had a patient who we had The Code Discussion with, a guy in his early 80s who had a hip replacement, and he emphatically said that he wanted to be DNR/DNI. We recorded his wishes in the chart. End of story, right?

Except the next day, the patient's wife called us into the room. She said she wanted to change her husband's status to full code. He wasn't particularly happy about it, but was agreeable. She said to him, "I'm not ready to lose you yet."

That story, to me, demonstrates two important facts about code status:

1) When elderly patients are made full code, it's often family members pushing for this status, rather than the patient himself.

2) People not in the medical field really just have no concept of what survival rates are when somebody goes through cardiopulmonary resuscitation.

For a patient over 70 years old, the chance of ever leaving the hospital after being resuscitated is only about 18%. But it gets better. If you do leave the hospital, you have a 60% chance of going to a nursing home, a 50% chance of having moderate to severe neurologic deficits, and a 50% chance of dying in the next year.

So basically, if you have CPR and are over 70 years old, your chances of returning home and not having severe disability are well under 10%. And the worst of it is that the person often pushing for the full code status isn't the patient who actually has to live through it.

I believe that patients over the age of 70 should not be given the option to be full code. That removes the stress and anxiety of having to make a decision, especially when the decision is not based on facts. Yes, maybe that 5% of people who would've lived happily for several more years might be sacrificed. But we will save 95% of people from weeks or months or even years of suffering, save probably millions on medical costs that could be better utilized, and also remove the guilt from family members.

But that's just my opinion. I could be wrong.

26 comments:

  1. I completely empathize with you. Completely. I think performing CPR on the elderly is barbaric, especially if they have limited functional status prior to arrest. On the other hand, I'd probably move the age threshold closer to 80. I see so many healthy 70 year olds that I would be more comfortable with an arbitration further down the bell curve.

    However, surely you recall how this country reacted with cries of "death panels" when the notion of reasonable end of life care was proposed. I don't think Americans are anywhere near being ready for this idea. They'd consider it a death sentence, and many family members would probably keep the elderly from stepping foot in a hospital. Moreover, people loathe being forced into any decision. The best approach is awareness and education, even though it currently moves at a glacial pace. We just have to do better at painting a realistic picture. Who cares how much the truth hurts?

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  2. You must listen to the freakenomics podcast "are you ready for a beautiful sunset" you'll love it. It's about end of life care.

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  3. I agree with NeuroTrumpet that 70 might be too young, especially for women. I'm 70, still have all my original parts, still capable of spending 4 hours mowing my lawn (with a push mower), still capable of spending more than 4 hours several days a week shoveling snow during the winter, still clean my own gutters and do my own home repairs. Don't have high blood pressure or diabetes--or indeed any serious illness. And I'm female. Maybe you have to look at the individual before deciding they aren't worth any effort at all? OTOH, if I had an MI and you told me that the damage was such that I had barely a 10 percent chance of surviving a year, I'd shoot myself to get it over with.

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    1. While you're right that the individual should be looked at, one thing that no individual can escape is the effect of aging. A younger person, even if less physically fit than someone older, has a much greater healing capacity. People in the "elderly" age range are certainly in a better position if they're more fit, but they can't bounce back from a hard knock as easily as someone younger, and that knock will take a lot more out of them than it would for someone younger. It would be interesting to see data on survival rates and outcomes stratified by age and some assessment of fitness and overall health, but I wouldn't be surprised if the rates of successful outcomes with resuscitation still decline pretty sharply as we age.

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    2. I agree with the comment above. Keep in mind that being do not resuscitate doesn't mean you're not getting any care at all. That is the opposite of true. It just means that you won't get heroic measures taken in one very specific circumstance of your heart stopping or if you stopped breathing. And keep in mind that if this happened, you wouldn't be a healthy 70-year-old with no medical problems. You would be a 70-year-old with a serious enough heart condition that your heart just suddenly stopped working.  The data shows that your chances of ever going home again are remote in that situation.

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  4. I think some above advocating for more care are missing the point. The suggestion is not to deny standard care but to not make efforts to resuscitate after a huge adverse event. Our healthy 70-somethings, I among them, are included in the statistics. Personally, I go with the 90% non-survival rate and want to be DNR. Yes, I am a nice person (mostly) but I'm not going to make enormous contributions to society in my remaining years, and I really don't want to continue at some small fraction of my former self.

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  5. "Maybe you have to look at the individual before deciding they aren't worth any effort at all?"

    Why, what a good idea.

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    1. How it does agreeing not to give electric shocks to a person's heart equate to "not worth any effort at all"?

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  6. I think, Fizzy, that your idea of removing the option of full code over 70 is politically (and maybe morally) untenable. And it's clear you are just stimulating discussion and not advocating death panels. … All of us have seen someone code, maybe multiple times, and revived with CPR, only to linger for weeks to months in the ICU at amazing financial and personal cost if not to them, than certainly to their loved ones. … So maybe rather than eliminating the code option, we should have patients (and their next of kin) watch a short (not horror-film-status, but realistic) video of what CPR looks like, what someone in the ICU's quality of life is, etc. We should have to see a pie chart of the likely outcomes. And then we can have them fill out the form to be full code.

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    1. Unfortunately, a local large hospital in my area just voted against showing videos of an actual code in waiting rooms at the hospital because it was "too horrible." So we shield patients from seeing the horrible thing we're about to do to them.

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  7. Our current process for establishing code status is backwards. We operate on the presumption of implied consent for a highly invasive and morbid procedure, and make it difficult to withdraw that consent. Can you imagine everyone who had a pancreatic mass being automatically taken to the OR for a whipple, unless they signed a document in advance stating they did not want one?
    As a resident, it is part of my job to discuss code status with patients at the time of admission and prior to surgery, then enter the orders in the computer. To make a person full code I simply have to ask "Do you have a DNR order?" they say no, I click the box, done. If they say "no, but I do not want to be brought back if my heart stops" then I have to leave the room and go out to the nurses station, start the internet browser on a computer, go to the hospital website, print a DNR form, fill it out, document a discussion of status in the EMR, and, as the final insult, ensure that the attending of record signs the form within 24 hours. So to condemn a person to a brutal and 95% futile procedure I only need to click a box, but to ensure they are allowed to die in peace if they so wish I have to spend at least 15 minutes. Meanwhile the emergency department is hammer paging me about something or other. Long story short, unless you ask specifically or I really think you are going to die while I am taking care of you, you are going to be full code, and if you end up in the ICU with aspiration pneumonia, permanent brain damage, and a collapsed lung because CPR was successful, well, that is the price you pay for thinking you were going to be one of the 5%

    So think deeply about whether you want your body's last experience to be my hard hard hands breaking your ribs, and get a proper DNR signed by your primary physician with a copy on file at the local hospital and the nearest level one trauma/tertiary referral center, and never forget that Sarah Palin is either a moron or an evil cynic (possibly both) for killing the idea of paying your doctor to have this conversation with you.

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    1. As a resident, it's your job to address goals of care in all your patients. Oftentimes they have actually thought about it, and it is important at least to start the conversation even if no decision is made at first.

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    2. I start the conversation with every patient. Less than half or them have thought about it. Most of those who have, have no idea what it is they are thinking about. It is absolutely my job, but it is less important than a lot of other parts of my job, so if the patient has not thought about it or discussed it with their own physician they are usually getting the default full code.
      Anonymous 9/10 1943

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  8. Those videos are available and need to be required viewing for patients and family members. People need to know what they're asking for. Like the above, I doubt you could remove the option for any age no matter how useless the code would be, people need to make their own informed choices. And believe me, if I have that little chance of meaningful survival, please for the love of all that's holy, DON'T "make any effort at all."

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  9. Did you explain any of that to her? Perhaps if she knew what the odds were and how much discomfort her husband would go through, she might not be so emphatic.

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  10. Thanks, Anonymous 9/10 7:43 - So much of our health care experience (as practitioners and patients) is due to terrible systems - and sometimes it feels those are systems that no human or group of humans really control. But as the Sarah Palin comment points out, there are moments in time when these systems are put into motion (or not) ... There are places where thinking humans and groups of humans can make a difference. There should have been a huge outcry by the medical community when the death panel thing happened. It should have been HUGE. And there was some. But if people saw their doctors on local TV and demonstrating in their communities they might have paid attention. Unfortunately their doctors are too busy spending 15 minutes printing out forms and chasing down signatures and returning pages to have enough of a voice in our political system. What a pity. (Also - on another hot button note - I saw there was some stupid group that trotted out "Abortion Survivors" for a couple women to talk about how they were victims of their abortions. The wording was so awful when you consider that without legal and safe abortions there are hundres, thousands of abortion victims. That's something this country has thankfully not seen much of for three decades. But the more restrict abortions the more we will see it. ... And meanwhile the policies that decrease abortions the most - absolutely tried and true - are progressive policies that include FUNDING PLANNED PARENTHOOD! ... Okay ... Off my soap box and back to work.

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  11. My dad recently signed his DNR. While I hate it, I get it. I hate that he signed it because at 85, he's rotting away doing "nothing" all day and has no life. He's depressed, lonely, and ... I get it.

    When he was with me this past spring, he walked every day, had little chores to do (daddy do list), and smiled. A lot. He had a life.

    He is the 1%. A few years ago, he ... insert long story here ... and thanks to Mayo, he survived, intact, with a catheter, and IAD... on warfarin and some other meds (K+, etc).

    Anyway, the DNR takes the pressure off me to convince my mother to let him go. I hate it. Really hate it. Really really hate it ... but the question for the families is this:

    do they hate the DNR more than they hate the thought of their loved one suffering?

    I don't want to see my dad suffer and I hate his suffering far more than I hate the DNR.

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  12. People think about this the wrong way. I work in ED. We get out of hospital arrests. The chance of surviving these are zip.
    The thing people don't understand is that you're dead. You've died. You are no more. Your body has stopped working. There is a tiny tiny chance that we can get you body to start working again. This chance depends on us beating your chest rigorously, shocking you, sticking you with needles, putting a tube down your throat. If you heart beat comes back, we then keep with in a coma state, not knowing if that time you were dead did a lot of damage to your brain. Your brain might already be dead, your kidneys might be dead, your bowel might be dead.
    If you are young, your body is better at healing itself and has less other diseases to deal with.
    But still, you were dead, and usually there's a good reason you were dead.

    This is not end of life care. You are already dead. This is being brought back from the dead care. and that is how I discuss it with my patients. "If you died in hospital and your heart stopped pumping, would you like the doctors to try to start your heart again? Knowing that it is unlikely to work and is a very invasive traumatic procedure?"

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    1. So you're saying that no one survives out-of-hospital arrests or survives with good neurologic recovery? It depends on the patient - and it may not be frequent - but the chances are not zero. That's why we make the point of installing AEDs in gyms and arenas.

      I also dislike the use of loaded language to frame these discussions, e.g. "pounding on chest" or "breaking ribs" or "very invasive". We don't describe a surgery in those terms, and it should not be applied to things like CPR let alone IV placement or intubation.

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    2. Can't find good outcome stats at this time. Only that ~10% survive til D/C from hospital. Can't find info on brain damage/organ damage etc. and this is obviously much higher for in-hospital.

      I'm not advocating for not doing CPR. I'm advocating for real, non-mystical conversations about what the procedures are and what the outcomes can be.

      If someone has cancer and is told that chemo (with all it's side effects) can lead to cure in 10%, then yeah, some people will chose against chemo. I think they should have this choice.

      Maybe we should describes surgery more like it is. Maybe the risks shouldn't be fine print. It's telling when doctors chose palliation or NFR orders more than patients do. I think we downplay the risks of what we do.

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  13. I completely disagree with any kind of blanket policy about who's appropriate for CPR or other elements of resuscitation. Certainly setting an arbitrary age limit doesn't make a lot of sense. As ever, it depends on the context. Should the 84 year old with metastatic gastric cancer be full code? Of course not - but what about the 74 year old who has a bradycardic arrest in emerg after coming in complaining of syncope? A couple of compressions +/- atropine has a pretty good chance of resuscitation - and some pacing pads and/or temporary wires will temporize prior to placement of a permanent pacer.

    It's true that the statistics are dismal - especially for out-of-hospital arrests - but there's no shortage of people around with readily reversible conditions who will have good outcomes. The issue comes when goals of care discussions don't happen - or don't happen appropriately - for patients who are both unlikely to arrest for any reversible reason and who have little concept of what "life support" looks like.

    Another problem with the statistics is that the end point after CPR often involves withdrawal of care in the ICU/CCU. This is considerably influenced by clinical judgement about how "well" a patient is waking up, along with a lot of other often subjective factors. These include clinical experience and [i]gestalt[/i], but short of definite evidence of anoxic injury or actual brain death, outcomes are not altogether predictable.

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  14. Sorry I'm a bit late to this party... EXCELLENT post!!

    While I'm not sure about a certain age limit, I agree with all you said. Having been and ICU/CCU nurse for over 30 years, I've seen more than my share of travesties.

    Case in point~ Little old man who'd been in a nursing home for 20 or so years. His wife was in the same nursing home with end-stage Alzhiemers. Poor L.O.M. admitted to us with DX. of infarcted. bowel, and severe contractures (knees up to his chest). No DNR/DNI status noted; no DPAHC. No family.

    So of course they took him to OR to "fix" the ruptured bowel. Dear Lord in Heaven.

    Sheer torture, what they put that soul through. I felt dirty afterwards.

    That is why I have my DPAHC and all the other paperwork this state requires all filled out. Hubs is in agreement, and knows I'd come back to haunt him if he lets them code me!!

    And then there always the fun folk who want Granma to be 4 plussed, because they are stealing her SS $...

    Grrrrrrrrrrr...

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  15. I'm the child who took care of her elderly dad. Said father was admitted to the hospital with acute kidney failure and they wanted me to tell them if he was DNR. God help me but I tried to find out by asking what I should do. It took a good ten minutes to make the doctor understand that I had a mature, realistic view of life and that I wasn't going to be angry or offended by the truth.

    Once I was told the odds of him surviving resuscitation and the likely outcomes from that I was able to instantly decide to make him DNR/DNI. It should *not* be that difficult to find out such basic information and families should be told what they are condemning their loved one's to when they try to do the "right" thing.

    He was on hospice some weeks later and passed peacefully. Another thing that should have been part of the medical discussion.

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  16. In Finland, where I work as a doctor in the field of geriatrics, DNR orders are medical decisions made by doctors. So according to the law, patients (or the relatives, in case of incapacitated persons) may refuse resuscitation, but they may not demand resuscitation or "full code status" in cases where physicians deem the situation hopeless. There is no age criteria; the decision is made case by case. And frankly, the majority of my elderly patients very much agree that they do not want to receive cardiopulmonary resuscitation. (Of course the DNR status does not rule out any other medical interventions).

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  17. My 78 year old MIL with multiple serious health complaints and severe osteoporosis who goes in multiple times a year for pneumonia (on top of a serious lung disease similar to TB--except it's not contagious, plus horrible asthma) insists on being full code. She is in complete denial about what a full code would be. I've tried to tell her, but my words fall on deaf ears. I watched that German pathologist who has the autopsy show on Youtube--he did an autopsy for a group of people donating their bodies to his university. The 70 year old woman had extreme osteoporosis. He cut her ribcage off with poultry shears. I have a lot of serious health issues myself and was in an ER with stroke symptoms when an elderly patient who's family couldn't find his DNR came in full code.( I was in the trauma room, so they put me in the hall-so I had a front row seat.) It was horrible. You could tell the guy was dead, but the EMS still had to go through the motions--guy straddling him doing compressions, etc.) I shudder to think of my dh and me having to do that on my MIL if she collapsed during Christmas and our niece and nephews watching while the rest of the family refuses to see that MIL should just go on to heaven. I just don't get it. My mom is almost 71 and in great health, but she's seen what waits on the other side of heart problems. Both my parents got living wills/etc. when my dad's mom got sick with Alzheimer's and died a horrible death after suffering for years (one surprise visit to her first home found her tied to a chair, the second sent her to the hospital after a staff member pushed her in the closet and shattered her arm) I have a heart problem (PFO closure with POTS syndrome) that has sent me to the ER for adenosine and possible cardioconversion. I'm already like--ok, give me versed so I don't know anything going on. Being in the healthcare system as a doctor or patient opens your eyes as to how bad extending your life can be. What's the point if there's no quality of life?

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