DNR and cardioversion
Started by achieman
achieman said:
Nope.
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swaamedic said:
A DNR is NOT a "DNT" (do not treat). What you don't do are things that directly treat immminent or immediately lethal events - so you give pain meds, and pressors, and fluids and antibiotics, and you can give atropine for bradycardia or lidocaine or amiodarone for v-tach. However, if the patient loses their pulse, no compressions, and no electricity. Likewise for the BVM and intubation.
Apollyon said:
I agree with you in principle, BUT, asystole and ventricular arrythmias are known complications of electrotherapy. So, if you drive them into pulselessness...
- H
FoughtFyr said:
What do you mean? I'm saying DON'T shock them. And, even if interventions MADE the pt asystolic or go into v-tach/fib, I would honor the DNR and NOT shock them, or start compressions.
achieman said:
I wouldn't have a problem cardioverting them if they were DNR-arrest. Like said previously, DNR does not mean DNT. With the caveat and discussion of what we would do/not do if the tx was complicated by an arrest.
A stickier situation would be a DNR comfort care only; in most situations, I would be less inclined to cardiovert.
mike
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I've been debating about weighing in on this one. This area is so murky. So here it is, my "I'm an attending so you should all listen to me." hard and fast answer: It depends. Wow! How's that for some rock solid guidance?
Seriously, I would say that if the person is DNR because they have a debilitating illness and their quality of life is poor I would not cardiovert them. If they are DNR because they fear vent dependence or ongoing pain or the like then I would do it. My reasoning is based upon how much I think I can get the person back to where they were before the onset of whatever the acute issue is and how good or bed that situation was.
Seriously, I would say that if the person is DNR because they have a debilitating illness and their quality of life is poor I would not cardiovert them. If they are DNR because they fear vent dependence or ongoing pain or the like then I would do it. My reasoning is based upon how much I think I can get the person back to where they were before the onset of whatever the acute issue is and how good or bed that situation was.
I think a more important question is, why are you trying to control the rythym anyway?
Why not just rate control? Or by giving dilt, are they not responding? Are the unstable?
Even if a patient is NOT DNR, there are many cardiologists who wouldn't attempt to cardiovert anyway. (depending on the history, age, etc)
I agree with docB. It really depends. I just had a similar (though not quiet the same situation in the ED tonight)
As I was holding to a very unstable bimal fx, splinting it, my triage nurse comes in and tells me, I am giving you an emergent. WBC 20, bp 70/30 HR 130 from NH.
Me: WHAAAAAAAAA?
Nurse: Don't worry. The pt is DNR.
Me: SO???? The patient isn't dead yet! He's obviously septic. Tell one of the other doctors while I finish splinting this and get someone to get an IV>
Nurse: *huffy* but he's dnr.
Me: yes, but that doesnt mean we dont' do anything!
So, yeah. DNR doesn't mean DNT. but Id on't think I would go shocking an afib if I can get rate control.
Why not just rate control? Or by giving dilt, are they not responding? Are the unstable?
Even if a patient is NOT DNR, there are many cardiologists who wouldn't attempt to cardiovert anyway. (depending on the history, age, etc)
I agree with docB. It really depends. I just had a similar (though not quiet the same situation in the ED tonight)
As I was holding to a very unstable bimal fx, splinting it, my triage nurse comes in and tells me, I am giving you an emergent. WBC 20, bp 70/30 HR 130 from NH.
Me: WHAAAAAAAAA?
Nurse: Don't worry. The pt is DNR.
Me: SO???? The patient isn't dead yet! He's obviously septic. Tell one of the other doctors while I finish splinting this and get someone to get an IV>
Nurse: *huffy* but he's dnr.
Me: yes, but that doesnt mean we dont' do anything!
So, yeah. DNR doesn't mean DNT. but Id on't think I would go shocking an afib if I can get rate control.
I guess I was looking to see if there is a definitive answer such as: DNR means NO shock (defribrillate or cardioversion). I know a lot of times when I try to simplify terms for patients, I would tell the patient and family that part of DNR is do not shock when the heart stops. I suspect that family members of a patient with DNR status would be suprised/angry if they see paddles on that patient's chest even if it is cardioversion. I think most non-medical, TV drauma watching people don't know that the electric pads are used for other medical problems such as pacing and cardioversion.
For those who replied NO without explanation, care to elaborate on your selection?
For those who replied NO without explanation, care to elaborate on your selection?
97 year old with no heart, no kidneys, with severe bilateral pneumonia. Talked until I was blue in the face, but the family wanted the patient shocked, but no CPR (?!!!) Of course, pt goes into vfib. three shocks later, and the family decides well, maybe it is ok to let their mother go peacefully. I just hope my family doesn't hate me that much.
Annette said:
The easiest way out of these situations is to not offer that part of the resuscitation, which is perfectly ethical (married to an ethics graduate). Medical treatment is not like a chinese menu (shock but no compressions, drugs but no intubation). It would have been acceptable to say, "I'm sorry, but I'm not able to offer defibrillation without CPR, it just won't work." It's also acceptable to say "I'm sorry, but I can't offer anymore."
mike
We're kind of branching off into the realm of witholding care in general rather than when you have a specific DNR. But that's the situation we run into in the ER more than the other anyway.mikecwru said:
The problem that you run into by holding back is liability. I agree with mikecwru in that he has suggested the right thing to do. However, anytime you hold back care, even if you believe it is futile, you have some risk. The most common factor is the long lost relative with guilt issues who is going to work out their problems in a court room rather than a psych couch. Or the relative who doesn't really care but is told by a lawyer that they can get some much needed cash out of you.
As ER docs we don't have a long term relationship with the pt or the family. Even under the best of circumstances in the ER you are making decisions on the fly. This lends itself well to the phrases "rush to judgement" and "snap decision" thrown out in court by plaintiff's lawyers.
mikecwru said:
I didn't offer the shock only option, the family told me that was what they wanted. One of the extended family members piped up with "I've seen it done and work before!" (I really hate family members with "a little medical knowlege" sometimes!) If your ethics graduate has a way out of this, I'd like to hear it, because I get stuck too frequently for my comfort trying to explain what we can do verses what will work and is reasonable. I've been told that most lawsuits on the issue end up being that the family was never told about an option, however unfeasible or inappropriate.
Annette said:
I just refuse to do it. I've heard quotes that no one has been successfully sued over this. If the family member piped up and asked/demanded, I would say "I'm sorry, I'm not going to do it." Re: the guy talking about liability, you take risk with every decision in the ED and there are many decisions with more risk than this one.
A week or so ago, I had a guy with a brainstem bleed that was dead but just didn't know it yet. He started dropping his pressure. I started neo. I told the family "I'm going to treat his blood pressure, but when his heart stops, and it will, I am not going to do CPR, because it's simply not going to work."
mike
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Yeah, but is this the decision and the case you want to lose your house over?mikecwru said:
It's not a suit likely to be filed, and almost impossible to win for a plaintiff. If the patient's dead, no future medical costs. If they're nursing home residents, no future earnings. If you're in a capped non-economic damages state, then the chances of even finding a lawyer who will do more than laugh are nil.docB said:
