DNR. DNI. DNH. These are abbreviations for advanced directives(do not resuscitate, intubate or hospitalize, respectively). Patients, family members, health care proxies, and guardians may decide in advance the level of medical care the patient wishes during a health emergency. The ER staff is often faced with issues related to these choices. A patient from a nursing home or assisted living facility should have a copy of the patient's advance directives (AD) available on arrival in the ER. I stress the should, because there have been many instances in which erroneous information led to unwanted and futile resuscitation efforts.
This past week I went in to examine a septuagenarian who was in severe respiratory distress when he arrived from a nursing home. The EMT's told me the patient was a full code. Thanks to the hospital's EMR (electronic medical record) system I knew that the patient had chronic pulmonary and cardiac problems and suffered from dementia. A DNR was found in the pile of forms sent with the patient. I treated the patient with medications and when his family arrived they confirmed his DNI/DNR status and were grateful that we had given him some relief without compromising his AD.
Many years ago when the ER was not as busy as now, I went into to see an elderly man who was near death. There was no AD. His daughter arrived and I explained that even with intubation and ventilator support, her father's prognosis was poor. She asked me what I would choose if this was my father. My father died at home under hospice care with metastatic renal cell carcinoma. He died peacefully and in accord with his wish to die at home. I shared my experience with this woman. Together, we decided to let the natural course of the father's disease go untreated except for some mild sedation. She held one hand of her father and I held the other. He died peacefully in less than 15 minutes. She and I shared some tears and honored our fathers.
This past week I experienced the reverse of this outcome. An elderly man arrived in distress. His health care proxy and guardian was a cousin near to my age. There was no AD. When I explained the problem and offered care and comfort, she opted for full resuscitation. Respecting the family's wishes, I intubated the patient, put him on a ventilator and admitted him to the ICU. Primum non nocere. "First do no harm" is part of the Hippocratic Oath. I felt that instead of relieving this gentleman's suffering, I had prolonged his existence but not his life. I believe that family's request were given in good faith and in the belief that the patient should be given every chance of continued life.
A recent controversy, in reimbursement for primary care doctors, is whether the physician should be compensated for the time needed to help families making end of life care choices. It is frustrating for ER docs that during a crisis, my colleagues and I must ascertain from a distraught family as to how aggressively we should treat the patient. The time for an individual to make decisions about end of life care is when they are healthy. A trusted family doctor can be of great help to a person and his or her family in making informed AD.
My 91 year old mother resides in a nursing home. Three years ago it had become apparent to my siblings and me that she was not safe living alone. A clean, attractive and well managed assisted care facility was found and my mother moved into her "apartment". Several months later, Ma fell and broke her hip. She was trying to get a good seat at the movie being shown and had neglected to use her walker. One month later after successful surgery and rehab, she was back in her apartment. In early November 2010, she fell again and fractured her "good" leg. Do to advancing age, increasing dementia, and physical problems she was not able to return to assisted living and will need care in a nursing home.
My mother had made it clear to her children, after my father's death, that she did not wish to receive any resuscitation if she suffered a cardiac arrest. She was of sound mind and body, 77, and still working when she made this choice. When she was in preop this past November for the repair of her second hip fracture, I was by her side. The hospital and physicians had her DNR/DNI documents. I signed her operative and anesthesia consents. I told the anesthesiologist that no cardiac compressions should be given, even if she had a cardiac arrest under sedation. He protested and said that the anesthesiology department's practice was to perform CPR, even in patients who were DNR/DNI, if the cardiac event occurred during the surgical procedure. I was grateful that this physician promised to respect my mother's wishes and that my mother's surgery went well.
We are born and we die. All religions include some variation of life after death. Resurrection, reincarnation, or nirvana are all comforting to mortals. When I get home in the early morning after a ten hour night shift, my wife (if she hasn't left for work) asks me how the night went. I usually give a simple answer, "no one died". There are those patients who die under my care, and I can say "he/she had a good death".
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I don't think we realize all of what this entails until we actually experience it. When my mother spoke to me about DNR (before she was even ill), I firmly told her that I'd have medical staff do anything necessary to keep her alive; after all, she was my mother & I didn't want her to die. That disturbed her & she said she didn't want that. So she gave the decision making power to her brother, my uncle.
ReplyDeleteYears later, when she fell at home, she was taken to a hospice (she had been receiving home hospice care for her lung cancer, until then) & when I saw her she was barely conscious due to the heavy morphine she was given, for pain. A few days later, she peacefully passed, while I was sitting in a chair next to her. She died in dignity & with peace & not in pain. After she died, I found a note with the name of a book on suicide and a bottle of pills, hidden in an eyeglass case. She was frightened to die in pain. I realized at that point that I didn't understand her fears & that I was only thinking of how to keep my mother alive, but not the quality of her life. All I wanted was a "good death" for her, but I didn't realize exactly what that was, until I experienced it. Luckily, the hospice medical staff (& my mother)knew how to accomplish that.