The NY Times with an article on who should get the final say on DNR orders. The public sometimes may be misinformed about the effective of CPR from TV:
Some studies show that the long-term survival for hospitalized patients given CPR is about 15 percent; some find even smaller percentages. But according to a 1996 article in The New England Journal of Medicine, the long-term survival rate on TV medical dramas for patients given CPR was 67 percent.
This is a more common scenario:
The patient, only 35, had been in a persistent vegetative state for 15 years. Recently, he had developed septic bedsores and pneumonia. His kidneys were failing, and despite the feeding tube, he was losing weight. Now he was in cardiac arrest. He was dying.But the young staff doctor had no choice. The patient’s relatives, convinced that the man could communicate, had insisted that all revival efforts be made. So the doctor gave the patient a few mouth-to-mouth breaths, climbed on the bed and began vigorous chest compressions, trying cardiopulmonary resuscitation.
The patient was intubated, shocked with electric paddles and injected with epinephrine. Blood spurted as a central line was inserted into the large vein in his groin to administer medicine and fluids. EKG electrodes were placed on his arms and legs: streams of paper spilled over the floor, as the hospital room filled with people and shouted orders.
After 15 minutes, the doctors called the time of death.
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- EPO controversy
- Reflecting on CPR
{ 7 comments }
Consider the DNR implications OUTSIDE of the hospital. As a paramedic, I was faced with the dilemma on nearly a daily basis. Too many times I would arrive to find a dead or nearly dead (but not dead enough) patient and hysterical family members wanting me to DO something. No DNR papers, of course. The patient would be 80-something, history of cancer, infarctions, CHF, strokes, bed-ridden for months with the requisite bedside pharmacy, looking like a flesh covered skeleton, agonal breathing, glassed over eyes with fixed pupils … but damn that course v-fib!
I would beg the family, please get the papers, tell me no, throw me out of here, you do NOT want me to do what I am about to do. I will break ribs, jam a tube down the throat, pump toxic chemicals into the veins and once I start, I cannot stop until relieved by a physician. I am bound by law and my license.
One lady I transported many times still haunts me. We took her home from the hospital, to the doctor and back, sometimes to the ER when things got bad. She was pragmatic, she knew the cancer was eating her up and she was going to die. She was 67 years old. Her family, on the other hand, was hoping for that miracle, unable to face the truth that she would soon be gone. This was in a rural Tennessee county where the trip to the hospital could take 30 minutes or more. I got to know her well, during our many rides into the city, and back home again, where we would very tenderly transfer her fragile body back into her hospital bed in the living room of the house where she birthed her babies.
The day came when she was at the end. She was ready. We had spoken of it often. I had broached the topic of resuscitation and DNR … she said she wanted to be let go when the time came, but her family would not allow such thinking on her part. They would not allow her doctor to sign a DNR for her. This is the hills of Tennessee, mind you. Many rural women are still of the notion that their father/husband/son knows better than they and they obey them. Nothing I said could convince her that she ultimately made her own healthcare decisions. Between us, I did promise her that if I was there at the end, I would do my best to honor her true wishes.
So, the end was near. I arrived to find her with agonal respirations 5 per minute. BP was 86/44. The EKG had wicked huge PVCs with runs of fine v-fib. She was barely responsive to voice. I squared off with her oldest son, the most reasonable family member there. I told him, “She is dying, she has only a few minutes, hours tops. If I am here when her heart stops, I will have to start CPR. Her last minutes will be getting rushed to the ER in my ambulance. Would you all rather I leave now, so you can be with her in peace until the end instead?” He conferred with the rest, but they decided, they wanted me to do whatever I could to save her life. I wanted to cry.
The only chance she had of having a somewhat peaceful death, as she wanted, was to be presented to a physician that could declare resuss to be a futile effort, and honor her wish to pass peacefully. So we loaded her up and made a lights and sirens run to the ER, 20 minutes away. I put her on some oxygen, made her as comfortable as possible, wrapped my arms around her and prayed she would hold out long enough to get to the ER.
When we got there, I immediately sought out the on duty doc, whom I knew to be an advocate for end-of-life issues. He signed me off, and took over the hand holding until the family arrived. My lady actually did hang on for another couple of hours, until another son was able to get there from Atlanta. Though not at home, in her own bed, she did ultimately get her peaceful passing. The family did later seek me out and thank me for making sure that happened.
Dealing with natural end of life situations as a paramedic can be heart rending. The laws do not allow us to make overriding decisions, many physicians do not want to do so over radio or phone, and too many patients and family members are ignorant of the options and what those really mean. But I cannot imagine a public service ad campaign so address this … Just say “No” to CPR?
dittos lissakay
From the article:
“Extreme cases like this one are rare.”
HUH? What BS !!!! Scenarios like this are playing themselves out right now in every ICU in every hospital in the nation.
As an intensivist I try to explain this until I am blue in the face, but family members insist upon torturing and prolonging their loved ones existence. It is freakish. As a doctor there is often little I can do. If I override family orders I am accused of “playing God” and lawsuits follow. Yes CJD, lots of them.
I blame the patient for not making this clear during their life. I blame physicians and nursing homes for not presenting this tougher. I blame lawyers and the legal system that leaves little protection for doctor abandoning futile care. Mostly I blame family for doing putting loved ones through what they would never do to an animal.
” If I override family orders I am accused of “playing God” and lawsuits follow. Yes CJD, lots of them.”
How many?
How many?
Approaching nearly 3/yr.
I have been yelled at by primary cares for intubating their patients who are “DNR” because the orders were unclear. Not exactly a complaint I take seriously, these families deserve their loved ones to get full court presses for being so unclear. Most Nursing Homes will tell the ER a patient is “full code” even when clearly a DNR. Easiest thing to do is everything. Fuck ‘em, i’m answering to the piece of shit lawyers, not the human beings.
don’t you worry about being “sodomized” for battery if you’re intubating against someone’s wishes?
don’t you worry about being “sodomized” for battery if you’re intubating against someone’s wishes?
The DNR order is rarely present, and even if it is it’s rarely clear. I won’t do a “full court press” if the DNR order is intact, but that’s once in a hundred cases. You’re much more likely to get sodomized for witholding treatment.
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