Another approach to the very difficult decision faced by the hospitalist described by Dr. Forrow in the May issue (“Deciding about CPR when a DNR order is confusing”) is offered: A DNR order is present but confusing. The elderly patient has multilobar pneumonia, delirium, a witnessed aspiration and then arrests with pulseless electrical activity. She has a very poor prognosis when one considers the extensive pneumonia and the subsequent type of arrest while undergoing hospital care. In hopes of doing no harm to this elderly patient in whom aggressive care would mandate CPR, translaryngeal intubation, mechanical ventilation, nasogastric tube placement, sedation, likely application of mechanical restraints, placement of multiple intravascular catheters and a bladder catheter, would it be acceptable to adhere to the recorded DNR order?
The DNR order was confusing, and proceeding with CPR might be justified on that basis. However, that decision is much more likely to represent a heavy burden rather than benefit to this 91-year-old individual. In an attempt to balance burden to benefit in this patient's care, I hope I would have recommended following the DNR order, as imperfect as it was. The subsequent explanation to her daughter should include the physician's great concern about subjecting her mother to invasive care with little hope of beneficial outcome. Last, some physicians may be hesitant to agree with this approach since the patient described was resuscitated and lived to go home to hospice care after a 30-day hospitalization. However, do we often ask such patients at discharge, a highly selected group, if they believe we made the proper decision by initiating intensive care (CPR, etc.)? I well remember a similar patient's response to this question: “Doctor, never do this again.”
Clifford Zwillich, MACP
The article about DNR status really depressed me. I work in the ICU and am constantly subjecting patients to ICU torture during their last few hours/days on this earth. Many physicians, patients and family members find it very difficult to address end-of-life issues in the first place. Once someone has made a decision, especially a very elderly individual like the one in your scenario, to then reverse it is cruel. It is very clear to me what “DNR but can intubate” means. It means that in the event of an isolated respiratory issue, you can intubate the patient to give them a trial of response, but if the disease has progressed to the point of cardiac arrest, they do not want to have their ribs broken and the resulting pain from an intervention that is unlikely to benefit them. Survival to discharge for inpatient CPR is 11% to 21%, with lower rates for those over 70. If the patient even makes it out of the hospital, they are usually much worse off than prior to admission.
To suggest that “DNR but can intubate” means “Do CPR if the heart stops” goes against the patient's and family's wishes and eliminates a valid option that some patients may wish to choose.
Please spend future time encouraging physicians to initiate discussions with family members and all patients over 80 and any patients with late-stage disease. It is much easier to address this before it becomes a crisis. The end result would be more patients dying with dignity in the presence of family and with adequate pain control, rather than surrounded by the chaos of a code blue and all the pain and suffering that accompany it.
Nancy Lawless, ACP Member
The well-commented case Dr. Forrow describes is not uncommon. Similar situations will be encountered often as nowadays DNR orders are made proactively like home DNR. Understanding of what a DNR order means can vary from person to person, as illustrated in this case. People think differently when not in a particular situation than when they are in such a situation themselves.
Can a physician decide to resuscitate if he or she deems the clinical situation to be reversible, such as choking and hypoglycemia leading to cardiac arrest, even when a DNR order is in place? This will lead to lots of discussion. Though it seems clinically appropriate, how the ethical and legal issues will play can be variable. Err on the side of life?
Apputhury Praisoody, FACP