When to say when?

[roja]

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I am wasting tons of time on SDN this afternoon and came across a good thread in the gas section:

http://forums.studentdoctor.net/showthread.php?t=500403


We just had one of our joint ICU conferences around a similar issue: DNR/DNI and what does it mean.

Because its an hour discussion and we have great ICU faculty, we easily took out of the discussion patients who don't have a DNR/DNI or those that come in without them with no family.


So, the question really became what does DNR mean and does it ever mean DNI? does it every mean don't transfuse etc? Does a DNR ever mean: just give me a comfortable death?

(you can talk hospice all you want but many many people are not comfortable watching someone die and they end up in our ED wether we like it or not).

 

[Janders]

Having recently completed a MICU month, DNR/DNI debates are fresh in my mind.

My general approach is that if a patient comes in with a generic (albeit real, signed) DNR/DNI order I will do everything until a code situation comes up. Thus, they get a central line, they get pressors, they get transfusions. They basically are just spared the compressions and shocks.

This is where communication with the family is key. The more you can communicate with them, the more they can explain exactly what their father/brother/daughter desired. You can explain the futility of intubating, or the possibility that pressors may be helpful. This, of course, is the biggest problem in the ED. Patient comes in, possibly from a semi-hospice status, with rumor or perhaps provided DNR/DNI, and in extremis. What is one to do? I think we have to err on the side of full speed ahead resus, unless you have a very clear-cut signed DNR order in front of you.

Once we all have computer chips in the back of our necks we can just update our code status daily, and this won't be such a big deal 🙂

 

[roja]

What do you do if they have a DNR but not a DNI. and they are 90 and demented? 65 with cancer? 70 w/ COPD?

 

[MedicFL]

I am just a medic so take what I say with a grain of salt. But here in FL a DNR unless specifically spelled out includes withholding intubation, and really any airway unless its an obstruction. EX: Grandma is found to be agonal respirations at 4 a min and is in V tac/ V Fib, we do nothing except respect the wishes. In FL the DNR have boxes that can be checked showing what they would like to be done or what they want withheld. But a DNR nonspecific we treat it as they don't want anything, unless family wants to provide more information to us. The problem I have run into start asking family questions and one says one thing and the other says a totally different thing.

 

[kungfufishing]

The ones I dislike dealing with/find confusing are when the patient has instructed the durable power of attorney relative that they "never want to have to go on life support...for any long period of time". So I ask the family what this means, and they say "well, if they'll come off the ventilator soon intubation is OK, but if they will need it for a long time or if lots of other stuff needs to be done to keep them alive then dont do it".

I didnt realize that my training included predicting the future.

 

[anonymousEM]

I have had a few that were DNI but do "everything else"...um, who let these people fill out these forms this way? I guess if you had an isolated arrhythmia, shocks would help but otherwise CPR with no oxygen won't go too far.

This discussion also comes up in my public health classes a lot as we discuss how US universal health care would be different from that in other countries...our culture values doing everything medically possible until the last possible minute. It is not a bad or a good thing inherently but different from the places that decide not to put elderly people on dialysis and make other similar decisions.

 

[EM_Rebuilder]

I think DNI is a term that needs to be left out of medical lingo...it just confuses thing.

DNR encompasses intubation, chest compression, anti-arrhtymics, and pressors is the sketchy part of the equation. I personally think it should always be an all or nothing (none of this well, you can do all that stuff but i dont want on a breathing machine). When I (recall I am an intern) but when I talked DNR to someone, I specifically mention intubation/breathing machine, chest compressions, heart/drug shocks, and medication to keep the blood pressure high....and then document document document.

What gets me is that in any code/traumatic type injury.. whats our A? Airway. Therefore, IMHO, if someone is DNI, whats even the purpose of 'everything else' if I can't even follow the first rule...take control of the airway....


I think the OPs purpose in this thread was more with the rushed in ED patient with the DNR in hand, how do we interpret that DNR...who explained it to them and what was their ideal intentions.... who knows....

 

[Aloha Kid]

Very very complicated and emotionally draining. I just had two cases last night.

The first case was a 86y nursing home female septic shock patient we intubated only to realize when the POA arrived she was DNI/DNR. From there it seemed to be one confusing mess as we debated over pressors, abx, ICU care etc. After a lot of emotion and going back and forth on what to do mainly by the family - the attending led the discussion and said "she's going to die whether we do anything or not, lets just take the tube out as she would want." We took the tube out and the patient died.

The lesson I learned: Families sometimes don't want to hear options, alternatives, and likelihoods. They want simple blunt direction. This family was ready for it.

The second case was a 78y nursing home female septic shock patient w/ acute renal failure, hyeprkalemia, GI bleed, INR 5. She came in with DNI/DNR papers and her POA was at bedside. When I talked with her, the patient had been ready to die. Comfort measures - including no dialysis, no blood, no antiarrythmics, no correction of electrolytes were agreed upon. POA new she could very well die in a matter of minutes. However, despite this knowledge her decision and commitment waxed and waned as evident when my attending talked to her. Whereas my discussion led to comfort care, my attending was able to convince her of ICU measures mainly for the correction of hyperkalemia, antibiotics, fluids, and possibly even dialysis. Now I must say, I don't agree with my attending and what he did. But even he has opinions that could easily persuade a fragile POA's decision. I told him I disagreed with this but said I accept it because he is the attending.

The lesson I learned: Only one representative from the medical staff to discuss with them the plan = one decisive plan of action. Families deserve not to have to make the decision all over again two times. We must be instinctive and assertive and supportive once we know the POA has considered the facts. We cannot betray their minds.

 

[WilcoWorld]

I had a case on a man in his 70's on hospice for colon CA come in with chest pain. He's telling me that he wants therapy, and what makes it worse is that he's got an LBBB that meets Sgarbossa criteria. So, now not only do I have the ethical issue of a life threatening, but treatable, condition in someone on hospice, but I also get to argue with a cardiologist over whether Sgarbossa criteria are useful...ON THANKSGIVING!

As if that wasn't enough, the guy's wife then explains to me that he was put on hospice earlier that week, "Because that's what our insurance plan said we should do."

Welcome to the wonderful world of clear-cut decision making that is EM.

 

[EM2BE]

I have somewhat dealt with this with 2 family members recently.

First one had a DNR because he knew it was the end (met cancer to too many areas, including the spinal cord). He was in the hospital over a weekend for them to shrink the spinal cord tumor if possible so that he may be more comfortable. He got hospice on a Monday and died Wed at his house.

The other had a DNR with the don't do chest compressions, intubate and all that, but didn't mind an IV to correct an electrolyte imbalance or an oxygen mask when she needed it (she signed a DNR 10 years before she died, and was ready at that point). She was put on hospice on Wed and died on Friday.

(yes, this all happened in the same week, so having the DNRs ahead of time and knowing their wishes made things much easier)

I think DNRs can vary obviously between patients, depending on their situation in which they get one signed. I think this is the determining factor as to what the patient wants. (the whole point of the stories above)

 

[spyderdoc]

I like the thought of changing the DNR terminology altogether. I read in one of throw aways that there is a move to change from DNR/DNI to AND (allow natural death), or something like that...I think that it is better to explain to the family that we are allowing a natural progression vs interfering with it.

I tend to say it this way and the families seem to be more comfortable saying, yes, please allow grandma to die a natural and comfortable death....

 

[deleted77919]

I heard one family just outside the ICU having an argument over a DNR. One family member was upset that her mother had a DNR. She was against withholding care because she wanted her mother to die a natural death, when it's her time. Apparently "natural" and "when it's her time" means after as many interventions as possible.

 

[roja]

The point of the original post was simply to generate discussion. Only through extensive discussion (not just here but in general) are these issues going to even remotely come close to being solved.

DNR (if you even exclude the whole DNI issue) is complicated business. The legalities very. The legal waters are potentially messy (you can get sued if you dont, sued if you do). The ethical issues are even murkier.

In NYS, DNR only encompasses, technically, CPR and ALS. So pressors, abx, fluid resusc, etc are not covered. However, the 'spirit' of a DNR often does- particularly when you are talking about the extremely old, sick, demented patients.

However, there is no guiding concensus. The only way to start establishing these is to talk about cases, ideas, thoughts etc and explore them as a community.

We have a discussion dedicated to this once or twice a year, held jointly with our ICU staff. It helps alot.

 

[Old_Mil]

DNR/DNI

Curiously, it rhymes with "let 'em die."

 

[Jeff698]

I read in one of throw aways that there is a move to change from DNR/DNI to AND (allow natural death), or something like that...

Thanks for posting this. This very much appeals to me and I think I'll start using this in my discussions with patients and families.

The DNR/DNI nomenclature is standard and I'll have to use that, but I really like the Allow Natural Death concept as a way of discussing this very emotional and painful concept.

Thanks!

Take care,
Jeff