Wednesday, October 25, 2006

Making Sure They Know

Several months ago, I responded to a code at the hospital and found a scene straight out of some medical drama. The patient was in asystole -- which means no electrical output from the heart -- but the code team labored mightily, with CPR and everything else they do, and it worked.

People don't come back from asystole very often. That code team knew their stuff.

And then it turned out that the patient was DNR.

DNR, for those of you who don't hang out in hospitals, means "Do Not Resuscitate." It meant that the patient had filled out a legal form requesting that heroic measures not be taken in the event of a code (no breathing or no heartbeat). DNR means, "If you find me dying, let me go."

The subject of advanced directives and living wills is more complicated than I'm qualified to address, although I can tell you that they're important. These documents tell medical caregivers your wishes in the event of any number of medical situations. If you're in a coma, do you want to be on a ventilator? Do you want fluids, tube feeding, antibiotics, blood transfusions? Who has your power of attorney if you can't make your own decisions? And so forth.

These documents vary from state to state, but all of us should file them. (Gary and I haven't, yet; we don't have a regular will, either. Do as I say, not as I do.)

But back to DNR. For obvious reasons, if medical personnel aren't absolutely sure that someone's DNR, they'll resuscitate. If someone's coding and the information isn't right there, the default is resuscitation. The patient I just described was being transferred from one part of the hospital to another, and his records hadn't quite caught up with him when the code started. Likewise, I once saw a nursing-home patient brought into the ER, after having been intubated by the ambulance crew in the field, because the nursing-home staff panicked: that patient had a DNR order on file, but in the oh-my-god-she's-not-breathing terror of the moment, anyone who knew that forgot it, and anyone who didn't know forgot to check.

This is very hard on families. It's one thing to have accepted that your loved one doesn't want heroic measures. It's another to see your loved one on a ventilator in the ICU, after heroic measures have mistakenly been taken, and to have to make the decision to turn off the machines.

An ER nurse I know says that this happens all the time. The DNR's on file, but the people who need to know that don't. Hello, heroic measures.

I was thinking about this the other day, and it occurred to me that there should be something you can wear on your body if you're DNR, something an ambulance crew will find right away. And, sure enough, Medic Alert will store your advanced-directive information and link it to your bracelet or necklace. (I'm not quite sure from this webpage if they'll actually put "DNR" on the jewelry itself.) In the meantime, I wonder if hospitals put color-coded wristbands on DNR patients, the way they do on patients who are likely to fall. I'm sure somebody does this. If not, it would be a good idea.

This sounds ghoulish, I know, but in the long run, it's kinder to everybody.


  1. Easier, yes, but sadly not legal...

    I'm pretty sure the medic alert thing wouldn't be legally binding, either.

    There is a agreement among nurses that, at a certain age, we are al going to get DNR tatooed across our chests... but it wouldn't be legally binding, either..

    But, the truth of the matter is, if a signed DNR form, with an identifying picture is not presented to the first repsonders (read, paramedics or ED docs) the resucitation MUST start (unless obvious signs of irreversible death are apparent). Once it has started, it CANNOT be stopped unless a doctor is willing to certify death.

  2. Hi, John! My parents both have advanced directives, but those documents don't include pictures. Maybe this is a detail that varies by state?

    Given what you've said, I guess DNR patients need to keep those documents strapped to their bodies?

  3. This is definitely a challenging situation of ethics, one I'll probably face if I end up becoming a medical ocial worker. Or, at least, I'd end up trying to help pick up the pieces. I'm not sure there's an easy answer.

  4. Hmmm. Okay. How about a signed and laminated photo-ID card, like a driver's license, that people could keep with them. Would that work for legal purposes?

  5. Actually, the photo thing is a requirement for a hospital to accept a patient from a nursing home as a DNR without an accepting doctor ordering it. The nursing home must send a (standard in Arizona) bright orange paper listing what they do and do not want, with a signature and a picture of the resident (very common in nursring homes, as the nurses change so frequently, its good for them to know who is who). As for the paramedic on the street, I know there has to be some form of legal paperwork, but I am not sure what exact form it must take....

  6. Anonymous3:04 PM

    this is such a serious issue. of course health care professionals must abide by the law, but in many cases, the law is not compassionate. i also think it makes lots of sense to have standard DNR procedures for those from assisted living and nursing homes. one doesn't live in such places without reason, and the usual reason is advanced old age often accompanied with poor health. we talk about caring for the planet and using scarse resources reasonably. the same ethic should be applied to the inevitability of death. Sharon

  7. Hi, Sharon! Thanks for stopping by!

    I sympathize with your position, obviously, but I can also see the other side: there could be a real danger of abuse, a slippery slide into euthanasia. So I think DNR has to be decided on a case-by-case basis: the problem lies in how to get people the information when they need it.

  8. Hmmm...we don't require photo ID on a DNR.

    And I know of one hospital that used purple wrist bands as a DNR sign.

    But believe me, if I hear one more time "they said the patient is a DNR but they couldn't find the paperwork", I am going to scream. Because it seems that what happens at these nursing homes is that they can't cope with a patient actually dying and so they panic and call 911.

    Put the darn DNR paperwork for each patient in a file right on the desk and grab it for the medics when they come in.

    I mean, really.

  9. David Harmon2:50 PM

    The DNR Tatoo may not be "legally binding", but it certainly scotches that "lost the paperwork" riff!


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