DNR status in a demented patient

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Colba55o

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Glad I managed to avoid this case,,,

96 y/o lady brought to pre-op for hip hemiarthroplasty for hip fx. Nursing home resident. History in our antiquated computer system is scant and all we know is she has rate controlled A-Fib, with an EKG to that effect, HTN, and dementia that has been "worsening over time" She is thin, somnolent and chronically ill appearing but vitals are stable with a normal cxr the hospitalist ordered.

I tried to pre-op this lady which was very difficult. She was oriented to person and place but told me the year was 1946. She was able to converse and make sense maybe 60% of the time and even though she was able to articulate that she had broken her hip and was in the hospital for a "hip replacement surgery" I did not think she was capable of truly giving informed consent. Per hospitalist, her only next of kin was in the hospital herself and about to die and no attempt made to contact anyone else. The lady was able to tell me she had a son that was in another country but couldn't provide any other info.

So this lady is also DNR/DNI...trying to discuss this with her was extremely difficult and while she did say "if something happens may as well let God take me" she was not able to understand the concept of rescinding the DNR for surgery as an option.

How would you all proceed? Medicine has "cleared" the patient, with no other workup. Surgeon got the lady to scribble a line on the surgical consent but then decided to do a two physician consent saying this case was emergent and she would die without it. OR is all set up to go and everyone is waiting on you to bring her back.

I'll just say what happened...a coworker relieved me while I was pre-opping. Proceeded with the case and DNR status was ignored; patient coded at the end of the case. The anesthesiologist gives rounds of epi and staff give chest compressions and manage to get her back after several minutes and she is dropped off in ICU on a vent, put on levophed to barely keep bp above 90.

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Pent sux tube.

They aloud gave respected the dnr.

If you are not sure how to proceed, you can bring it to the ethics committee.
 
An emergency hip fx? That is absolutely ridiculous and it sounds like your Orthopod is a complete DB. Will the patient eventually die from something like this if left untreated? Sure ... but this is an emergency that needs to go within the hour or even DAY? No way, definitely need to get the DNR status resolved and if you can't, gotta get your hospital lawyers and ethics committee on it. What your colleague did could get him/her in a lot of trouble.

I am sure each hospital has a policy, I doubt there is a uniform consensus on this. But I believe each admission the DNR/DNI has to be renewed, so even if there was one last week and the patient comes back, it does not automatically stay with the patient. Another issue is, what if the patient came in through the ED with a real emergency, then what? If it's in the middle of the night on a weekend, I would proceed with surgery and treat the patient as a full code. In a "non-emergency case" such as the one above (again let's be real, that is not an emergency), then the whole DNR/DNI thing needs to be sorted out.
 
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"I'll just say what happened...a coworker relieved me while I was pre-opping. Proceeded with the case and DNR status was ignored; patient coded at the end of the case. The anesthesiologist gives rounds of epi and staff give chest compressions and manage to get her back after several minutes and she is dropped off in ICU on a vent, put on levophed to barely keep bp above 90."


And there's the $$$$$. Sad. Rather than palliative med, massive $$ cost at the end of life.
 
An emergency hip fx? That is absolutely ridiculous and it sounds like your Orthopod is a complete DB. Will the patient eventually die from something like this if left untreated? Sure ... but this is an emergency that needs to go within the hour or even DAY? No way, definitely need to get the DNR status resolved and if you can't, gotta get your hospital lawyers and ethics committee on it. What your colleague did could get him/her in a lot of trouble.

I am sure each hospital has a policy, I doubt there is a uniform consensus on this. But I believe each admission the DNR/DNI has to be renewed, so even if there was one last week and the patient comes back, it does not automatically stay with the patient. Another issue is, what if the patient came in through the ED with a real emergency, then what? If it's in the middle of the night on a weekend, I would proceed with surgery and treat the patient as a full code. In a "non-emergency case" such as the one above (again let's be real, that is not an emergency), then the whole DNR/DNI thing needs to be sorted out.

DNR/DNI does not need to be renewed each admission. There is a state issued POLST form, which patients can fill and keep, can show paramedics to stop CPR and resuscitation...
 
Couldn't she have just got a couple pins and call it a day?
Emergent fracture in this patient seems laughable, between the DNR issues, consent issues, unknown history issues, etc.
There's no way I would have done it emergently unless she had intractable pain, ischemic leg, etc.
Giving a demented, DNR, 96 year old woman a shiny new hip sounds almost criminal. I guess Medicare reimburses well for hips?
 
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This is a 30 min case in my facility. It's either a pinning or a Gamma Nail.
If she was "as good as she can get" then I don't see a big issue with proceeding as long as everyone is clear on the DNR plan. But we don't know that this was the case here.

As IlDestriero and others stated, in no way is this an emergent case. Sort out the details. But maybe the details were sorted out prior to anesthesia involvement. If the hospitslists and ortho have already addressed the DNR details then we go to the OR. We don't know exactly what was addressed in this case so we are only speculating.

This is an extremely inconsiderate statement but you do what you can in these situations to improve the pt but in this case if things go wrong, as they did, who is gonna make a stink about it? This lady has nobody.

The plan of attack would have most definitely been to get ethics and legal involved early. Not 10min before going to the OR. That is the job of the surgeon and hospitslists.

Bring the case to PEER Review and make some policy changes so this doesn't occur again.
 
This is an extremely inconsiderate statement but you do what you can in these situations to improve the pt but in this case if things go wrong, as they did, who is gonna make a stink about it? This lady has nobody.

I agree with everything you said except this can come back and bite you in the rear. Next thing you know, a daughter or POA who nobody seemed to know about at the time comes out of the woodworks and sues everyone. Maybe not likely but certainly possible. In anesthesia, we play by that statement all the time.
 
This is pretty much a routine case at some of the hospitals I cover. Pt >90 years old, demented, sick as s***, DNR/DNI (sometimes and sometimes not), Hip fracture, currently stable, no family, 2 physicians sign for surgical consent, nobody signs anesthesia consent (which is separate) and they expect you to do the case because there is now surgical consent and you obviously cant have surgery without anesthesia, surgeon needs to get this done calls it urgent or emergent.. They really put you in a position you cant really get out of and even if you do, its going to go the next day and it will be your colleagues headache. So what are you supposed to do? If you do the case you're taking very obvious high risks and if something happens family/administration will ask you why you did it. If you don't do the case, there will be a BIG stink about it pissing off administration and they will question your ability and confidence and weather or not you should work there. I've had these issues come up with multiple colleagues who are great at what they do. I'm sure many here can relate. This is what the future of medical practice has come to and its sad. Its all about the $$..
 
I think we all understand that the right thing to do here is palliative care. I'm not an orthopod so I can't be the one to decide if the right thing is a troch nail vs a hemi-arthroplasty vs whatever. But she probably ought to get that fracture immobilized sooner rather than later. Demented people feel pain.

We had a lengthy thread recently about rescinding DNR for the duration of a procedure so I won't rehash my opinions on that here.


She was oriented to person and place but told me the year was 1946. She was able to converse and make sense maybe 60% of the time and even though she was able to articulate that she had broken her hip and was in the hospital for a "hip replacement surgery" I did not think she was capable of truly giving informed consent.

[...]

she did say "if something happens may as well let God take me"

I will take what may be a contrary stance to most here, and say I would have no worries about accepting her signature as consent for the procedure. She knows her hip is broken, she knows she's in the hospital to get it fixed. There was meaningful 2-way communication with the patient. She's articulated awareness of the material risks of the procedure, including the risk of death. I'm less concerned that she doesn't know the date.

I would ask her WHY she wants her hip fixed. If she says "it hurts" that's good enough for me. If she says "so I can go dancing" then maybe that's a reason to believe she doesn't understand what's happening.


Surgeon got the lady to scribble a line on the surgical consent but then decided to do a two physician consent saying this case was emergent and she would die without it.

Emergent? :laugh:

We get old hip fx patients who can't consent themselves all the time. It takes just a few minutes to get a witnessed phone consent from the patient's spouse, adult child, parent, adult brother or sister, any other relative, or any random person "who has exhibited special care and concern for the individual" ...

If none of those people exist, the answer is the hospital ethics committee. I can count on one hand the number of times I've ever had to go that route. But when it's the right answer, it's the right answer.


I'm with Noyac, this case should go to review, for no other reason than the 2-doctor claim of emergent need. That's obviously fabricated, an outright lie, for the sake of expediency. If they're lying here, what else are they routinely lying about?
 
Thanks for all the replies..I'm relatively new (<2 yrs out of residency) and had no idea how I would have handled this if my senior colleague hadn't inherited it at the last minute.

I'm at a small community hospital and I know I'm supposed to be on the "ethics committee" but have yet to have a meeting with them and getting an opinion from such committee at 8pm on a Friday night would be doubtful. I'm also pretty sure that our DNRs do not need to be renewed every admission.

I will insist we bring this case up at M&M. So many issues
1) The on call orthopod documented that this hip hemiarthoplasty was a necessary and emergent procedure. Maybe he's an dingus, maybe incompetent, but can I as an anesthesiologist argue that he is wrong or that he should be doing a natural nail/pinning instead? That seems out of my scope of knowledge even if it makes sense that it isnt emergent.
2)I don't believe this patient truly could give informed consent, but based on our conversation, I would have accepted her scribble on the anesthesia consent. Definitely a slippery slope but we all have different criteria for capacity I guess
3) The biggest issue was the DNR. There was NO way I could get any kind of answer from this woman whether she'd want to rescind it for the surgery, we just know at the time she signed it she wanted to be DNR. Suppose this was a truly emergent surgery and you couldn't reach family to discuss? Do most hospitals have an on-call ethics committee you can call in the middle of the night?

Noyac I thought the same way you did, if she has nobody who cares, but if this son she mentioned finally reappears he could make trouble for everyone involved.
 
A few things to think about Colba55o.
1) you may not be in a very good position as a newly graduated attending to argue with a seasoned surgeon about his approach. Hopefully, some of your seasoned partners will step in to help and smooth over the conversation. If not then, well you should remember that one when the partner needs a hand from you I guess.
2) I obviously don't know what knocked off this pt but the procedure performed and the timing of the arrest tell me it was showering of fat from the hemiarthroplasty. Hopefully, this surgeon at least knew better than to pressurize the femur. But I'd he is doing a hemi on a demented 96yo then I'd bet he didn't know not to pressurize either. Was this orthopod seasoned or new? Very very poor choice IMO and he essentially knocked this pt off. Clean kill. Headshot! I would be sure to ask this question in the PEER review.
3) I didn't mean that since she has nobody then nobody will care. I was just stating that it is sort of a blessing in this **** of a case.
 
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Who made the patient a DNR in the first place? Is this something she wanted or asked for at some point? Someone had to make that determination or decision. If she's competent to make herself DNR, then she's competent to give consent. If she's not competent, then the DNR is moot anyway, unless you can identify who made this decision, in which case there is someone floating around out there that can give consent.

"There is a fracture - I must fix it". Absurd yet all-too-common concept.
 
She made herself DNR and presumably had the capacity to make that decision at the time she made it. By the time I met her, she understood that she was DNR and what that meant, but she could not follow the concept of rescinding the DNR for the surgery, or at least I was unable to effectively communicate that to her.
She was somnolent and likely more confused than normal at the time she showed up at preop after being in hospital, getting pain meds etc.
Sad to live on Earth for 90+ years and wind up alone when it counts
 
This is pretty much a routine case at some of the hospitals I cover. Pt >90 years old, demented, sick as s***, DNR/DNI (sometimes and sometimes not), Hip fracture, currently stable, no family, 2 physicians sign for surgical consent, nobody signs anesthesia consent (which is separate) and they expect you to do the case because there is now surgical consent and you obviously cant have surgery without anesthesia, surgeon needs to get this done calls it urgent or emergent.. They really put you in a position you cant really get out of and even if you do, its going to go the next day and it will be your colleagues headache. So what are you supposed to do? If you do the case you're taking very obvious high risks and if something happens family/administration will ask you why you did it. If you don't do the case, there will be a BIG stink about it pissing off administration and they will question your ability and confidence and weather or not you should work there. I've had these issues come up with multiple colleagues who are great at what they do. I'm sure many here can relate. This is what the future of medical practice has come to and its sad. Its all about the $$..

Exactly. This case is a dime a dozen. Usually an afternoon add-on when you are already busy as crap. If I see a case like this being added on I usually try to get upstairs beforehand to sort through end-of-life issues (finding family to read them the riot act). Not easy to see patients upstairs sometimes but it is better that trying to sort through all these issues when the patient arrives in the holding area.
 
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The more I think about his case the more I realize just how good we have it at our facility. The surgeons and nurses usually have all of this worked out by the time the pt gets to me. They have a ph # for me to call to get consent from POA or they tell family to stay put because the anesthesiologist will want to speak with them or the POA/family is brought with the pt to the holding area.

This is rarely an issue.
 
I'm supposed to be on the "ethics committee" but have yet to have a meeting with them and getting an opinion from such committee at 8pm on a Friday night would be doubtful. I'm also pretty sure that our DNRs do not need to be renewed every admission.

Doubtful, if not downright impossible.
 
The more I think about his case the more I realize just how good we have it at our facility. The surgeons and nurses usually have all of this worked out by the time the pt gets to me. They have a ph # for me to call to get consent from POA or they tell family to stay put because the anesthesiologist will want to speak with them or the POA/family is brought with the pt to the holding area.

This is rarely an issue.

Same for us, and the family is told surgery will be cancelled if they dont answer the phone :)
 
3) The biggest issue was the DNR. There was NO way I could get any kind of answer from this woman whether she'd want to rescind it for the surgery, we just know at the time she signed it she wanted to be DNR. Suppose this was a truly emergent surgery and you couldn't reach family to discuss? Do most hospitals have an on-call ethics committee you can call in the middle of the night?

My $.02.

There are lots of interesting issues here. But the DNR isn't the biggest one. However, you're perseverating on it, so here goes.

Right, you can't get an answer from her. Whether she's able to consent for surgery (express understanding of her situation and the proposed treatment and r/b/a) and whether she's able to reason through something relatively complicated like rescinding a DNR perioperatively are different challenges. I mean...many NON-demented patients can't think through DNR, let alone a perioperative DNR rescindment. So you're left with what a reasonable patient would want and what a reasonable physician would do.

IMO, a reasonable patient would want to "be" DNR in situations where in event of a severe cardiac or respiratory derangement or arrest, full and meaningful recovery is not immediately or reasonably achievable. I think this is what most patients mean when they decide to become DNR. Obviously in the perioperative setting there are lots of immediately and fully reversible causes of above and that's why we commonly rescind a DNR perioperatively.

All of which is a long way to say, why the f do you care so much if the patient can understand a perioperative DNR rescindment or not? YOU'RE the doctor. Autonomy is a great thing and all but you don't need to be a slave to it in these kind of extenuating circumstances. Ethics doesn't need to be involved. The patient has consented for the surgery and even if you don't buy that consent, there is a degree of implied consent in her just having been brought to the hospital from her home/facility/SNF. I hope you know the answer to the situation "what if this was a truly emergent surgery and you can't reach family?"
 
She made herself DNR and presumably had the capacity to make that decision at the time she made it. By the time I met her, she understood that she was DNR and what that meant, but she could not follow the concept of rescinding the DNR for the surgery, or at least I was unable to effectively communicate that to her.
She was somnolent and likely more confused than normal at the time she showed up at preop after being in hospital, getting pain meds etc.
Sad to live on Earth for 90+ years and wind up alone when it counts

In practice, what happens in the (admittedly ****ty) situation that you presented is, the patient goes to ICU tubed and on pressors, family is reached, sometimes they press on for a few days or sometimes they withdraw care immediately, and if family can't be reached (like, any alive blood relation counts), ethics gets involved. At least in my state, it takes a LOT to withdraw care on an unrepresented patient. Agreed that it is a sad and suboptimal situation. Also agreed that the tendency is to "do more" for people who are likely to get minimal benefit. But unfortunately for unrepresented patients, the best you can do is advocate for the patient, provide your best care, and move on.
 
The real question here is: why did she code???
We can debate back and forth endlessly the ramifications of violating DNR, and all the legal aspects of informed consents in demented patients, but what really needs to be debated is why we allowed this frail elderly woman to code under our care???
We should be able to do better than that!
 
The real question here is: why did she code???
We can debate back and forth endlessly the ramifications of violating DNR, and all the legal aspects of informed consents in demented patients, but what really needs to be debated is why we allowed this frail elderly woman to code under our care???
We should be able to do better than that!
That's really the question and hopefully will be the focus of the M&M, though I suspect it won't.
Why did she arrest, and could it have been avoided. (With a different surgical or anesthesia technique, different intra op management, should there have been any pre procedure studies or additional historical data obtained that would have changed the course, etc.)
 
That's really the question and hopefully will be the focus of the M&M, though I suspect it won't.
Why did she arrest, and could it have been avoided. (With a different surgical or anesthesia technique, different intra op management, should there have been any pre procedure studies or additional historical data obtained that would have changed the course, etc.)
I gave my #1 reason. I think her heart failed after the showering of fatty emboli from the femur. She should not have had a Hemi and definitely not have had it pressurized if they did this. Not a whole lot we as the anesthesia team can do about this. 90+yo hearts don't tolerate this well.

Drop a TEE on these cases once in a while. You will be amazed at the showering that occurs.
 
Like others have said, this is a rare occurrence but when it arises, it is best to know what to do. I am curious what the critical care docs do because I am sure they see this more often than we do ... a sick, elderly demented patient comes in to the ED from the nursing home, there's a prior admission with a DNR/DNI order, no family available or that anyone can get a hold of, and of course the patient is on the verge of coding or requiring intubation.

In this example, I still say the easy answer is delay surgery to sort out the details rather than forge ahead and treat her as a full code which was done in this case. On the converse side, what if the story was a 96 yo pleasantly demented patient with a DNR/DNI order with free air, perfed bowel, and septic with BP in the 70 and 80s and pH of 7.1. Then what?
 
Like others have said, this is a rare occurrence but when it arises, it is best to know what to do. I am curious what the critical care docs do because I am sure they see this more often than we do ... a sick, elderly demented patient comes in to the ED from the nursing home, there's a prior admission with a DNR/DNI order, no family available or that anyone can get a hold of, and of course the patient is on the verge of coding or requiring intubation.

In this example, I still say the easy answer is delay surgery to sort out the details rather than forge ahead and treat her as a full code which was done in this case. On the converse side, what if the story was a 96 yo pleasantly demented patient with a DNR/DNI order with free air, perfed bowel, and septic with BP in the 70 and 80s and pH of 7.1. Then what?

Comfort care.

Alternative is months of medical torture.
 
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Comfort care.

Alternative is months of medical torture.

Definitely agree but how many surgical heroes would take her to the OR? I am sure there are many out there that would be rushing her to the OR and calling this an emergency. Heck, I did a ruptured AAA on a similar patient in residency even though we knew it would be futile but of course vascular forged ahead. Who knows how much blood and products were given only to get her upstairs as quickly as possible to let her expire.
 
Like others have said, this is a rare occurrence but when it arises, it is best to know what to do. I am curious what the critical care docs do because I am sure they see this more often than we do ... a sick, elderly demented patient comes in to the ED from the nursing home, there's a prior admission with a DNR/DNI order, no family available or that anyone can get a hold of, and of course the patient is on the verge of coding or requiring intubation.

With merely a prior admission with a DNR/DNI order, and let's assume no supporting documentation like a palliative med consult or a "goals of care" note in the chart from a doc who knows the patient well, I personally would provide full care until family can be reached.

With a POLST, however, you do what the POLST says. Hopefully the POLST in this situation says "fluids and abx only OK" or "comfort only"
 
On the converse side, what if the story was a 96 yo pleasantly demented patient with a DNR/DNI order with free air, perfed bowel, and septic with BP in the 70 and 80s and pH of 7.1. Then what?

Comfort care. Alternative is months of medical torture.

This is a case where knowing the goals of care is more important than knowing the code status.

This patient (or the patient's advocate, relaying what they think the patient's wishes would be) may indeed want to have a painful surgery followed by a lengthy hospitalization in the hope of a return to the premorbid condition. Or not. But knowing what those goals are is the key.

In the absence of a family member (good) or a POLST (better) saying no surgery, no pressors, no intubation etc., in this case I think you proceed.

And nimbus, you're merely imposing YOUR goals of care on the patient. Are saying you wouldn't want your pleasantly demented 96 y/o granny to have a life saving operation? Who are you to decide that this patient's life isn't worth saving? What if it was a 60 year old, healthy? What if it was a healthy but demented 70 year old? 80 years old? 90 years old?
 
This is a case where knowing the goals of care is more important than knowing the code status.

This patient (or the patient's advocate, relaying what they think the patient's wishes would be) may indeed want to have a painful surgery followed by a lengthy hospitalization in the hope of a return to the premorbid condition. Or not. But knowing what those goals are is the key.

In the absence of a family member (good) or a POLST (better) saying no surgery, no pressors, no intubation etc., in this case I think you proceed.

And nimbus, you're merely imposing YOUR goals of care on the patient. Are saying you wouldn't want your pleasantly demented 96 y/o granny to have a life saving operation? Who are you to decide that this patient's life isn't worth saving? What if it was a 60 year old, healthy? What if it was a healthy but demented 70 year old? 80 years old? 90 years old?

I was raised Catholic, learned all about sanctity of life and all that.

But a pH of 7.1 in a 96 year old is what it is. I would tell the family my honest medical opinion which is that it is futile care. And the chance of a prolonged painful hospital course leading to death is much greater than a chance of meaningful survival.

She won't be dancing at her great granddaughter's wedding.
 
I was raised Catholic, learned all about sanctity of life and all that.

But a pH of 7.1 in a 96 year old is what it is. I would tell the family my honest medical opinion which is that it is futile care. And the chance of a prolonged painful hospital course leading to death is much greater than a chance of meaningful survival.

She won't be dancing at her great granddaughter's wedding.

In this story, there is no family available, she is possibly a DNR/DNI, she thinks it is 1946 and that you're her prom date. The chances she will need to stay intubated are 110%, coding is probably 50%, and the surgeon is screaming in your ear that there is no time and you are delaying him which will lead to her death.

In that situation I believe it is ok to treat her as a full code for those very reasons ... emergency surgery, no family available to clarify DNR/DNI order, and she is demented and does not understand exactly what you mean by rescinding the DNR order. If I get sued for that, that is one of those things you gotta just get through and wonder where our society has evolved to.
 
In this story, there is no family available, she is possibly a DNR/DNI, she thinks it is 1946 and that you're her prom date. The chances she will need to stay intubated are 110%, coding is probably 50%, and the surgeon is screaming in your ear that there is no time and you are delaying him which will lead to her death.

In that situation I believe it is ok to treat her as a full code for those very reasons ... emergency surgery, no family available to clarify DNR/DNI order, and she is demented and does not understand exactly what you mean by rescinding the DNR order. If I get sued for that, that is one of those things you gotta just get through and wonder where our society has evolved to.

Unfortunately it depends on the surgeon. Most of ours wouldn't do that case but I suspect a couple would. You are correct.
 
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