Saturday, April 17, 2010

DNR’s: Yes or No?

A couple of days ago I responded to a post from Rogue Medic, one of my EMS friends who happens to be an incredibly prolific writer. Something that he does that I really like is that he researches virtually everything he writes about. And one thing that I’ve really found to be true, especially with his writing, is that arguing with facts is extremely difficult. To that end, reading some commentary to his posts can be pretty amusing. I’m often reminded that it’s extremely difficult to “have a battle of wits with the unarmed.”

Anyway, recently he wrote about an article detailing a cardiac arrest save where the physician (who was the author of the article) encountered family who produced a Do Not Resuscitate order for the patient.

The article – and RM’s commentary – are interesting in that they are different. For the sake of forming an independent opinion, reading is recommended. Also, the references are solid; there are a number of them that support the post, and while I did not read them thoroughly, I did skim them. They are also worth looking at for background.

I have some thoughts of my own. While my thoughts may not be as concise or as well-researched as either RM or of Dr. Veysman (the author of the article), I hope I can express them at least somewhat cogently.

On two different occasions recently I’ve worked cardiac arrests where I’ve found out afterward the patients involved had DNR orders in place that we weren’t aware of at the time we worked the patient. One of them wasn’t all that long ago; I wrote about it, in fact. As it was, this patient had numerous health-related problems that were quite significant, including renal failure and diabetes. And while our efforts to resuscitate him were successful in the short-term, he died two days later in the hospital’s ICU.

We were not made aware of the existence of the DNR until about an hour after we brought the patient into the ED. It was pretty frustrating, at least for me; what if we were made aware of the DNR order when we arrived on scene? Obviously the outcome would have been different: we would have called our medical control resource and spoken to the physician on duty, described the situation, and notified the doc about the DNR. Under those circumstances, we would have not worked this particular patient.

Death with dignity? Probably so. More than being alive with what was likely irreversible brain damage for a couple of days post-resuscitation.

Another situation I encountered – again, not all that long ago – was the exact opposite of this. Dispatched to one of the area nursing facilities for a cardiac arrest and notified while we were responding that an active DNR was in force. When we arrived we were met by the officer on the engine who reiterated what we were told. By law we are obliged to verify that the patient is, in fact, dead. This requires actually examining and assessing the patient.

I brought the cardiac monitor into the facility and when we went inside we were directed to where the decedent patient was located. Sure enough, he was definitely dead and had been so for a while. Asystole in all of the leads we could look at simultaneously. Cyanosis in the extremities and the face. The beginning of rigor mortis. And a current, valid DNR order.

Now did this patient die with dignity? The only thing that would  make me question whether that was the case is the facility this individual was in.

There is another side to this. It’s personal – what would I want if it were me in the position of patient? Up until now, I haven’t really thought about it much. And I still really don’t know what I would do if it were me in that position. And – to go a step further – I am my mother’s health-care proxy. If something catastrophic were to happen to her, I would have to make a decision. One thing she doesn’t have is a DNR order – because of this, decision making becomes somewhat more complex.

And now – because of the facts and opinions that I’ve read – I have to think about it. How can I not?


Rogue Medic said...

Exactly the point of an advance directive.

I have considered the inevitability that I will die some day. While I still have the capacity to make these decisions, I have decided to let people know how I would like this handled when it does happen.

Walt Trachim said...

You and I are in total agreement.

As far as I know, she is a full code. I say this only because she answers in the oblique whenever I bring it up, which tells me she doesn't want to talk about it.

That is hard to deal with; trust me on that. And I can't force her to do something she doesn't want to do.