DNR without DNI?

[smartparts]

Do you guys typically offer to make patients DNR without also making them DNI? I'm not talking about patients who have conditions that are likely reversible such as pneumonia. Mainly asking about patients with many comorbidities who would be unlikely to be extubated if they were ever intubated or have advanced dementia/COPD/CHF. I've always felt that CPR and intubation cross a certain line and if they are unlikely to bring the patient back to a reasonable baseline, they should not be offered separately. I've seen too many DNR patients get intubated then end up on the vent forever because the family can't bring themselves around to terminally extubate. What do you guys think?

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[Raryn]

I do offer that one. I never offer the opposite though. If you don't want to be intubated, I keep describing acls to you in greater detail until you decide to go DNR.

You can have a purely respiratory problem without losing your pulse. For those, we can intubate you. Whether or not you're DNR is irrelevant. If you have difficulty coming off the vent, well, hopefully we discussed your wishes with you and your family when we were anticipating your circumstances. Patients can always get a trial of intubation with plan to extubate to comfort care vs trach if it fails.

On the other hand, being DNI only is stupid. Outside of a limited vtach arrest that I can immediately shock you out of, chances are if you want me to code you, you'll be intubated during recovery. If the patient is DNI only, I refuse to force myself (or my team) to potentially have a prolonged code where we aren't allowed to get an airway. I talk to the patient about what a code actually consists of and try to gauge whether they truly want to have no possibility of ever going on the vent. If they're certain, we inevitably share the decision to go full out DNR/DNI.

 

[todbaker37]

Having a code discussion is tough and Its hard to make blanket statements. I have done it before (intubation without DNR) and even had one patient the reverse way around despite my best intentions of telling them that that makes no sense at all. In some patients it can make sense to be okay with intubation but DNR such as PNA or COPD exacerbation where they might actually be able to be extubated to get their affairs in order or spend more time with their loved ones.

I honestly stopped having my code discussion in a "a la carte" type of manner. I was so foolish as an intern back then and thought I was helping by presenting my patients families with all the endless possibilities. My upper level was quick to teach me a lesson. For example, I'm embarrassed to say it but as an intern I asked questions that no person outside of medicine would have the slightest idea of what it most likely meant such as :"Would you like chest compression's? What about intubation? What about defib and cardioversion? Blood Products? ICU level care? Central line? Pressors? ECMO?" To this day I still cringe over that conversation, but you live and learn and thats what residency is for. Over time you develop a style, some people may end up disagreeing with your style but I find its best to present the facts, offer your opinion if asked, and listed to what the family thinks the PATIENT would have wanted if there is no paperwork.

 

[IMreshopeful]

I usually phrase it as such
- do you want us to do things like shock you, press up and down on your chest aggressively to pump your heart, and force a tube down your throat if you were to die unexpectedly with your heart stopping?
- if you were to lose control of your breathing would you want us to stick a tube in your throat, hook you to a machine to breathe for you with the hope of trying to wean you off of it? (I typically tailor this to the situation in terms of whether the patient is likely to do well after a code)
- I emphasize that the patient can always change their mind.

If someone tries to be DNI but resuscitate, I just flat out refuse and say they're either full code or DNAR/DNI.

 

[Siggy]

I honestly stopped having my code discussion in a "a la carte" type of manner. I was so foolish as an intern back then and thought I was helping by presenting my patients families with all the endless possibilities. My upper level was quick to teach me a lesson. For example, I'm embarrassed to say it but as an intern I asked questions that no person outside of medicine would have the slightest idea of what it most likely meant such as :"Would you like chest compression's? What about intubation? What about defib and cardioversion? Blood Products? ICU level care? Central line? Pressors? ECMO?" To this day I still cringe over that conversation, but you live and learn and thats what residency is for. Over time you develop a style, some people may end up disagreeing with your style but I find its best to present the facts, offer your opinion if asked, and listed to what the family thinks the PATIENT would have wanted if there is no paperwork.

The problem is that some of it makes sense. No compressions, but please defib v-tach/v-fib? Makes sense. What about cardioversion if a patient can't make their own decisions? DNR, but yes to cardioversion isn't unreasonable.

Advance directive/code status is like a pyramid. The actual DNR is the very top, and if any of the layers below it (intubation, defib, medications, etc) is removed, then the top has to be removed as well. However, just because the top is removed (don't code me if I die), doesn't mean the rest is gone too (please do everything to keep me from coding).

 

[Mad Jack]

Plenty of people get tubed that don't need resuscitation. Damn near half of the bad COPDers I used to see were DNR but not DNI, as they were just used to getting tubed at that point.

 

[QuizzicalApe]

DNR only is not all that uncommon.
I've taken to calling DNI Only "Satan's Code Status", though. It makes absolutely no sense. When I'm covering patients and have a DNI only patient signed out to me, I try to find an excuse to go talk to the patient about it. I usually see DNI only as a fancy way of saying "Best case scenario, I want a successful CPR so I can die from suffocation".

 

[jdh71]

Sure. The DNR but not DNI dies make it awkward when they have an arrest following intubation. Which is a fairly high percentage of sick hearts. I've watched one guy just pulse less vtach away while bagged him and he magically got a perfusing rhythm back.

I just tell these patients, "cool, but just so you know the intubation could kill you so"

I don't even care anymore. People are stupid and irrational. We all are I suppose. I'm still billing for my services one way or the other. Maybe I'll be less cynical tomorrow.

 

[smartparts]

Regarding the DNI-but-not-DNR code status: one of the attendings where I work emphasizes that early intubation doesn't improve outcomes in codes which I thought was kind of interesting. I wish I had the citation from that lecture.

My approach is to offer DNR and DNI as kind of a package at first, then back off an allow for a possible DNR-only if its met with even mild resistance. With that, however, I'm brutally honest about the likelihood of extubation. For the COPD-ers with literally no diffusing surfaces left in their lungs I say that its "highly unlikely" they will come off the vent, but for CHF patients who have a reasonable EF I suggest that it could be a bridge to recovery.

 

[Raryn]

Regarding the DNI-but-not-DNR code status: one of the attendings where I work emphasizes that early intubation doesn't improve outcomes in codes which I thought was kind of interesting. I wish I had the citation from that lecture.

It doesn't. But they compared early intubation to late intubation during a code, not early intubation vs no intubation.

If it's anything except a 1-2 round code with a quick return to whatever mental status you had before the code, you should be tubed and supported through the next few days (+/- hypothermia). Anything else doesn't give you the however tiny chance you otherwise might have.

 

[Mad Jack]

Sure. The DNR but not DNI dies make it awkward when they have an arrest following intubation. Which is a fairly high percentage of sick hearts. I've watched on guy just vtach away while bagged him and he magically got a put fusing rhythm back.

I just tell these patients, "cool, but just so you know the intubation could kill you so"

I don't even care anymore. People are stupid and irrational. We all are I suppose. I'm still billing for my services one way or the other. Maybe I'll be less cynical tomorrow.

I once had a patient vagal, go blue, start agonal breathing, and and lost their palpable pulse after I NTS'ed them that was a DNR/DNI. They had a neb setup, so I turned it on to 10L, threw it on them, and started sternal rubbing them like they was a newborn (noxious stimuli is the only thing that gets the little ones to breath sometimes- flicking their feet or whatever- turns out it works on the big ones too!). ****ing came right back after about three minutes, much to the shock of the family (that was in the room the whole time) and the team that had come in to discuss if there was anything the family wanted to do. Patient was actually related to someone I knew and I was just thanking my ****ing lucky stars that I wasn't the one that killed their family member lol. Like, they were well on their way to playing checkers with Jesus, but I didn't want to be that guy.

 

[doctorbeastmode]

agree with a lot of above. DNR-only is often the MOST appropriate code status - provided you specify you only want a few rounds of resuscitation.

The best neurologic and functional outcomes from an arrest happen from VTACH or unstable SVT that is shocked within a few minutes. If I had terminal cancer and went into VT, I would want a few rounds of compressions and a few shocks. Your chances of recovery with full neurological status are upwards of 70% even in crummy hospitals. If I didn't come back after that, I wouldn't want intubation or anything further. Prognosis after a thirty minute code - even with the best ACLS - is less than 30%. The idea that to get a shock or two (and a good chance of recovery) means I also have to sign up for intubation and a 30 minute code (and being an intubated vegetable) is completely bonkers.

The problem isn't that being DNR only is unreasonable, it's that our health system isn't set up for nuance. In an ideal world all patients would have a complex code status discussion that actually reflected their prognosis and end of life preferences. Instead, they often get a few haphazard questions crammed into the end of a long H&P followed by a dichotomous outcome in the EMR.

If someone wants one shock then comfort measures only, that seems like a totally reasonable and rational thing to request.

 

[Siggy]

Regarding the DNI-but-not-DNR code status: one of the attendings where I work emphasizes that early intubation doesn't improve outcomes in codes which I thought was kind of interesting. I wish I had the citation from that lecture.

True, in general in adult codes intubation doesn't change much.

However lets assume you get ROSC in a patient with a DNI? You're going to dedicate an RT to a BVM for the patient for 24/7? Or are you going to hope that what ever precipitated the code to immediately get cease and not cause respiratory issues in the immediate post code course?

 

[Crayola227]

my understanding with these ethics things is that there is some wiggle room, like in the case you describe @Siggy

the case could be made was that the doctor and patient did not foresee all the circumstances in which intubation would be required when the DNI status was entered, that it was not possible to get informed consent at that time, which opens up the discussion with proxies about what would the patient want in the particular circumstance
if there is a family member, POA, PCP, that can support that the patient likely would consent to this case of intubation, then you could do it

the only way that really bites you is if the patient gets well enough to sue you over it, or one of the family members does on behalf of the patient, but you can see how that would be unlikely in the case of a good outcome

the hospital would likely be the one to give you the hardest time no matter how good the outcome if you are not following policy

it would be ideal to contact the hospital's ethics board with these sorts of questions
obviously there's plenty of occasions that's not feasible

the point of the DNR/DNI status discussions is to accomplish what the patient wishes are, but that doesn't have to mean rigid adherence to such labels if you end up in a situation where logic says it runs counter to what the patient's wishes are

there's an element of common sense that actually can go into these situations and be legal

 

[FutureInternist]

If I'm pressing on your heart to get blood to go to your lungs to get oxygen, but there's no tube in your throat to give you the needed oxygen then it will be useless
If I give you oxygen with a tube but don't do any chest compressions to get the blood to go to the lungs, it will be useless

OR

A car only works if it has 4 wheels & the 4 wheels of coding are
Chest compression
Shocking the heart
Putting a tube in your throat to help you breathe
Giving you medications

I never do DNR but OK to intubate or vice versa except in very limited cases (COPDers, asthma exacs etc)

Similar discussion on another thread (that I started to possibly help new interns)

http://forums.studentdoctor.net/threads/discussing-code-status.1143485/#post-16716792

 

[Crayola227]

If I'm pressing on your heart to get blood to go to your lungs to get oxygen, but there's no tube in your throat to give you the needed oxygen then it will be useless
If I give you oxygen with a tube but don't do any chest compressions to get the blood to go to the lungs, it will be useless

OR

A car only works if it has 4 wheels & the 4 wheels of coding are
Chest compression
Shocking the heart
Putting a tube in your throat to help you breathe
Giving you medications

I never do DNR but OK to intubate or vice versa except in very limited cases (COPDers, asthma exacs etc)

Similar discussion on another thread (that I started to possibly help new interns)

http://forums.studentdoctor.net/threads/discussing-code-status.1143485/#post-16716792

nice, I was just gonna go dig up this thread....

 

[dozitgetchahi]

The problem is that some of it makes sense. No compressions, but please defib v-tach/v-fib? Makes sense. What about cardioversion if a patient can't make their own decisions? DNR, but yes to cardioversion isn't unreasonable.

Advance directive/code status is like a pyramid. The actual DNR is the very top, and if any of the layers below it (intubation, defib, medications, etc) is removed, then the top has to be removed as well. However, just because the top is removed (don't code me if I die), doesn't mean the rest is gone too (please do everything to keep me from coding).

The problem is that all of this gets very vague in practice.

For instance, I was involved with a QI project at our VA hospital regarding our code status menu in CPRS. Our menu was highly confusing and vague and included options like 'no pressors' (which was apparently intended to mean 'no pressors during codes'), 'no antiarrythmics', 'no resuscitation' (without clarity on which type of resuscitation), etc. All sorts of confusion grew out of this menu. For instance, did 'no pressors' also mean no pressors for sepsis in a patent with a pulse in the ICU? Did 'no antiarrythmics' mean no amiodarone for fast a-fib in a patient without other acute issues in PCU? There were literally nurses who were interpreting the 'no resuscitation' order as meaning 'no volume resuscitation'...etc. It was absurd, and nobody was really thinking about the implications of all of this when they went through this menu with the patients.

The further along I get in medicine, the more paternalistic I'm getting. I'm in favor of not giving patients options that are just downright stupid. Even in situations where you have lots of time and go out of your way to explain this stuff to patients, the information asymmetry is tremendous and a lot of patients end up a) getting confused, b) making objectively bad decisions that actually go against their stated wishes or c) throwing their hands up and saying 'gee, I donno, you're the doc - what would you do?' (which is especially popular among the >80 crowd).