Do Not Resuscitate and the need for a central line

Just the other day I was called to see a patient coming up to the Intensive Care Unit with a diagnosis of pneumonia. Upon my arrival the patient is “hanging in there” with the blood pressure in the 60’ and 70’s systolic.

This is a no-brainer situation – the patient is in sepsis and septic shock.

Early intravenous antibiotics and aggressive resuscitation is what this gentleman needs right now. Per the ER report he had already been given three liters of intravenous fluids with the blood pressure barely budging.

The patient needs a central venous catheter so that the vasoactive medications (vasopressors) could be given to maintain his blood pressure.

As I am grabbing the central line kit, the nurse is trying to reason with me – “Why do a central line if he is DNR (Do Not Resuscitate)?”

The patient was, indeed, DNR which means no aggressive treatment like mechanical ventilation or chest compression in case of a cardiac arrest. So, where do you draw the line between treatment, aggressive treatment and resuscitation?

There is no easy answer. It all depends on individual circumstances. Thus, there is a great deal of confusion among the general public and even health care professionals about this.

Talking to the patient (or the family if the patient is unable to communicate) is probably the only way that those important decisions should be made.

What to do if there is no time to talk, just like in the case above? In these cases we, physicians, often have to make that decision on behalf of the patient. The default tactic in most cases is to do everything you can to stabilize the patient first and then have a discussion with the family or the patient.

Not that you have to exclude the family at any point in the patient care process, it’s just that a Code Status discussion is better to have when things are relatively stable. The discussion often goes way beyond the question – “Do you want us to resuscitate him/her or not?”.

The family has to understand the implications of the decision they are making in the current situation.

Often, when asked about the code status for their loved one the family produces a living will – the document that is supposed to clarify the patient’s preferences on this matter.

Having read hundreds of those documents I can attest that the wording in most of those documents is just too general. Most living wills state something like: “If I am in a terminal condition and there is no reasonable hope for recovery…do not resuscitate.”

In some cases it is plain obvious that the patient is not going to do well. If the patient comes with a massive brain insult of whatever cause there is, indeed, no hope for recovery. Most cases, though, fall into the gray area.

Often, it is obvious that the patient is sick but things could go either way. And in the case of an adverse outcome the physician should be aware about what the patient’s wishes are regarding aggressive treatment and resuscitation.

The bottom line is – there is still plenty of confusion about the resuscitation status among patients and even healthcare professionals. Careful and timely discussion with the patient and the family is, really, the only way those decisions should be made.

Ralph Gordon is a critical care physician who blogs at realICU.

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  • http://www.thecentralline.org Graham

    There’s also a significant amount of debate whether DNR/DNI patients should be put in the intensive care unit as well.

  • http://www.parentingintheloop.com Lorette Lavine

    Difficult call but I believe it was the correct one in this case. As a nurse, I would need more info about this case to make a more complete assessment as to the patient care plan.
    But given the little information in the above post, I think that a central line and treatment is the only way to proceed.
    This is not heroic treatment here.

  • paul

    do not resuscitate does not mean do not treat.

    if meaningful treatment can be given to a dnr patient thru a central line, you do it. it varies case-by-case.

  • Primary Care Internist

    DNR means “do not resuscitate” as in CPR, not necessarily iv fluid “resuscitation”.

    But such confusion is widespread among patients and their families, nurses, and even doctors. That is why, in NY, we have a “MOLST” form delineating every possibility and wishes for such, very specifically. Families and patients can opt for

    -no antibiotics
    -no artificial hydration or nutrition (including iv fluids)
    -no pacemaker
    -no hospitalization etc.

    It seems a bit tedious to review this with patients and/or families, but really pays off when they become unstable and you don’t have to revisit the issue in a crisis. When grandma’s really crappin’ out in septic shock, you don’t want to present the possibility of not treating her with ivf/abx to the family, for their guilt that they’re “killing her” may ultimately take over the decision-making process.

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