Do not Resuscitate orders

[paramedicgirl]

NEVER sign a DNR order. It is an excuse for medical personnel to deny a patient any and all medical treatment.

Not where I live. It means no CPR, for cardiac arrest cases. DNR orders are only for patients with a terminal illness or who are at the natural end of their lives. What you are suggesting would be very unprofessional and no one I have ever worked with, doctor or paramedic would ever deny someone life saving treatment.

So, if a patient has a DNR order, they get medical treatment for their illness unless their heart stops, and they are clinically dead.

I just went out to the ambulance and read a DNR order. Nothing of what you say is true.

 

[epower]

What the contract says, and what is actually practiced are two different things. Unfortunately, there are people in the medical profession who can not read the DNR contracts properly.

 

[paramedicgirl]

What the contract says, and what is actually practiced are two different things. Unfortunately, there are people in the medical profession who can not read the DNR contracts properly.

There may be unethical practicioners out there somewhere, but I’ve never met one. A DNR order means no CPR. It does not mean to withhold other lifesaving measures.

All the DNR contracts are identical. They don’t contain different bits of information for each patient, other than name, address, age and doctor’s name. So how can anyone misread one?

 

[Pug]

There may be unethical practicioners out there somewhere

Do you trust all physicians and nurses to wash their hands appropriately? I don’t. If I can’t trust that, how can I trust something that could invoke their desire to help (by not letting you suffer), which I suspect is strong?

I’ve been a patient in a hospital. They are not trustworthy, not enough. They are too tired, too something. And they are way too likely to think they are right when I tell them they are wrong. They do not listen. How can I trust that? It makes a hospital stay a rather scary thing.

 

[paramedicgirl]

Do you trust all physicians and nurses to wash their hands appropriately? I don’t. If I can’t trust that, how can I trust something that could invoke their desire to help (by not letting you suffer), which I suspect is strong?

I’ve been a patient in a hospital. They are not trustworthy, not enough. They are too tired, too something. And they are way too likely to think they are right when I tell them they are wrong. They do not listen. How can I trust that? It makes a hospital stay a rather scary thing.

You are only partially quoting me, which makes it look like I said something other than what I meant. I’ve had great experiences working with wonderful, caring nurses and doctors who do what is best for every patient I bring them.

 

[Pug]

You are only partially quoting me, which makes it look like I said something other than what I meant. I’ve had great experiences working with wonderful, caring nurses and doctors who do what is best for every patient I bring them.

I’m sorry! I was trying to shorten it, and I see that the way I cut it changes the meaning, now that I look at it. I have no idea why I cut part of your sentence. I did understand that you trust doctors and nurses, that is specifically why I asked you about trust, because you clearly have it. I stupidly cut too much and didn’t notice.

 

[Traditional_Ang]

A general rule of thumb is that it is morally permissible to refuse treatment if the treatment itself is unbearable or overly burdensome (physically, psycologically and I have even heard in economic reasons, but I would hope that would be last resort type of things), not because the individual despairs about life. This includes DNR’s as permissible. Also in some instances at the end of life refusing food is acceptable (JP2 in his statement was more referring to people who can normally digest such as Terri Schiavo) because as it turns out, the food does more harm and they cannot properly digest it (some people worry you are starving them to death, but near death patients are better off not having food, just palliative care to treat pain and also stuff to keep hydrated). Hope that helps.

Daily Bread:

Could you please give the cite on the JP II quote, because most of the commentary on it that I’ve seen have stated that JP II had referred to using feeding tubes to provide nutrition to terminally ill patients as normal care which was to be differentieted from measures such as using respirators to keep terminally ill people alive.

Your Brother in Christ, Michael

 

[Traditional_Ang]

What the contract says, and what is actually practiced are two different things. Unfortunately, there are people in the medical profession who can not read the DNR contracts properly.

epower:

A DNR Order is pretty straightforward, unlike what you’ve seen on TV. Medical Personnel are obligated to follow it, no matter what their feelings or those of screaming family members.

Living Wills had problems as they tried to envision every imaginable situation and just couldn’t. Advance Directives solved that problem by listing 2 or 3 people who would be responsible for making Health Care Decisions if the patient were not able to make them and then giving them general guidelines as to the level of care and any specific things the patient didn’t want done.

wings.buffalo.edu/faculty/research/bioethics/adv-dir.html
hcdecisions.org/
caringinfo.org/i4a/pages/index.cfm?pageid=1

I think these will show how an Advance Directive works.

Your Brother in Christ, Michael

 

[Melissa]

Daily Bread:

Could you please give the cite on the JP II quote, because most of the commentary on it that I’ve seen have stated that JP II had referred to using feeding tubes to provide nutrition to terminally ill patients as normal care which was to be differentieted from measures such as using respirators to keep terminally ill people alive.

Your Brother in Christ, Michael

I can’t give a cite on that, but I can say that at the very end, feeding tubes to the terminally ill (and even hydration) can be stopped because they are causing more harm than good.

Anecdotes (I know–plural is not data, but I’m using these to illustrate):

Anecdote 1: My maternal grandmother had lymphoma, and attempted a week of chemo (she’d been given 80% chance of cure w/ a 16 week course, and decided to go for it). After that week, she just had complication after complication, ending up hospitalized and w/ a feeding tube. Between midnight and 3am, the decision was made and the feeding tube was removed. She died at 6:40am that same morning.

See–at the very end of life, the body systems start shutting down, so that you have the food being pumped in, but nothing is going out … causing the dying person to swell and experience great discomfort when she is no longer able to benefit from the nutrients in the food. Stop & removed the feeding tube … you save the dying person considerable pain. Note that death happened in a matter of hours … this is typical of someone who is actively dying … there isn’t a number of days of lingering while starving to death (like Terri Schiavo) … the body is calling it quits and continuing to pump food in is not going to change that fact.

Anecdote 2: Friend of the family–her mother diagnosed with bladder cancer. At the very end, they discontinued IV fluids because the mother wanted to die at home instead of the hospital. She, too, was dead in hours–and not from dehydration … continuing IV fluids would have just meant pumping IV fluid in, and pumping fluid out via catheter, but she was not benefiting from even hydration. I’m not going to begrudge any dying person their wish to die at home instead of in a hospital bed … it’s such a small wish, and she may have lived for an hour more w/ continued hydration … not worth the cost of keeping her in the hospital where her visitors were limited (less than her number of children allowed in).

The thing is, in the event of illness (rather than death by trauma), the body is naturally shutting down, system by system, and there is nothing that can be done to stop this process. So the question becomes ‘do you inflict additional pain on the dying just to soothe your conscience?’

As far as a DNR–there are absolutely times when it is appropriate to have one. The stuff they do to bring someone back from cardiac arrest is very rough on a person … and it’s important to ask whether you are going through this process for the good of the dying or whether it’s simply to allow yourself to ‘feel ok’ that everything had been tried, no matter what the cost to the dying person.

 

[quasimodo]

This is a thoughtful thread - well done. Use caution on DNR’s.
Pug’s suggestion (One can set up a durable power of attorney and appoint a person you trust to make decisions for you when you are not conscious.) is the best in most cases. Epower’s caution is a valid concern (NEVER sign a DNR order. It is an excuse for medical personnel to deny a patient any and all medical treatment.)

My FIL and his wife got all caught up in really fuzzy thinking about these cases when the news media blew one of them all out of porportion some years ago. The case where they wanted to remove the respirator from a woman who had been in a coma for years - only she did not die when they removed it. Well, they (FIL & wife) were not going to have anybody interfer with their choices. So they signed DNR’s for no apparent reason at WAY too young an age (~62) and without a terminal diagnosis. Something went south during a hospital stay and only a doctor ignoring the order kept him alive.

 

[oldfogey]

There’s a little bit of confusion later in this thread as regards the original intent of the post. The OP was asking about an elderly person with advanced Alzheimers, not someone 62 in normal health.

In the OP’s situation, a DNR order makes sense as the person will be able to die peacefully. A power of attorney really doesn’t apply, because the staff at a nursing home is not going to be able to take the time to make a phone call if they find a person in cardiac arrest or not breathing. They are going either initiate resuscitation or follow a DNR order on the chart.

It actually is a good idea for everyone to have a medical power of attorney, even people in their twenties, in the event they are incapacitated. But that does not apply the the OP’s situation, unless the designated person is actually sitting at the bedside when the emergency arises, and they are known to the nursing home as the designated party.

 

[Donna_P]

May God be with you!

Food and water are basic requirements to my understanding. My Grandmother (Nana) had hospice at the end in my Mom’s home. She died peacefully after several days. She was kept on pain medication but she got to the point where she no longer wanted to eat and her body just started shutting down. She was 94.

May God rest her Soul,

God bless you,

 

[quasimodo]

There’s a little bit of confusion later in this thread as regards the original intent of the post. The OP was asking about an elderly person with advanced Alzheimers, not someone 62 in normal health.

In the OP’s situation, a DNR order makes sense as the person will be able to die peacefully. A power of attorney really doesn’t apply, because the staff at a nursing home is not going to be able to take the time to make a phone call if they find a person in cardiac arrest or not breathing. They are going either initiate resuscitation or follow a DNR order on the chart.

It actually is a good idea for everyone to have a medical power of attorney, even people in their twenties, in the event they are incapacitated. But that does not apply the the OP’s situation, unless the designated person is actually sitting at the bedside when the emergency arises, and they are known to the nursing home as the designated party.

No there was no confusion … I was addressing the side bar conversation that had come up with regard to DNRs. I maintained that DNR’s should be used with caution, nothing more. A DNR is probably (almost certainly from my remote pov) the right thing in the OP case, but we should stress that the principles must be applied to each individual case - possibly by someone with PoA.

 

[paramedicgirl]

This is a thoughtful thread - well done. Use caution on DNR’s.
Pug’s suggestion (One can set up a durable power of attorney and appoint a person you trust to make decisions for you when you are not conscious.) is the best in most cases. Epower’s caution is a valid concern (NEVER sign a DNR order. It is an excuse for medical personnel to deny a patient any and all medical treatment.)

This is fear mongering. I repeat, there are no doctors or paramedics I am aware of who would ever be so unethical as to deny someone life-saving treatment when they have signed a DNR order. CPR is the exception. DNR means no CPR. A patient has to already be clinically dead for CPR to be administered.

My FIL and his wife got all caught up in really fuzzy thinking about these cases when the news media blew one of them all out of porportion some years ago. The case where they wanted to remove the respirator from a woman who had been in a coma for years - only she did not die when they removed it. Well, they (FIL & wife) were not going to have anybody interfer with their choices. So they signed DNR’s for no apparent reason at WAY too young an age (~62) and without a terminal diagnosis. Something went south during a hospital stay and only a doctor ignoring the order kept him alive.

Where I live, only a patient with a terminal illness or at the natural end of their life can sign a DNR order. It is not for healthy people.

 

[quasimodo]

This is fear mongering. I repeat, there are no doctors or paramedics I am aware of who would ever be so unethical as to deny someone life-saving treatment when they have signed a DNR order. CPR is the exception. DNR means no CPR. A patient has to already be clinically dead for CPR to be administered.

Where I live, only a patient with a terminal illness or at the natural end of their life can sign a DNR order. It is not for healthy people.

No it is not fear mongering.
I never adddressed paramedics.
Do you maintain that CPR is the ONLY treatment covered by DNR?
I never said he was healthy - I said he did not have a terminal diagnosis.

 

[paramedicgirl]

No it is not fear mongering.
I never adddressed paramedics.
Do you maintain that CPR is the ONLY treatment covered by DNR?
I never said he was healthy - I said he did not have a terminal diagnosis.

Where I live, DNR means no CPR. So, if a patient codes, then there are no chest compressions, no AED, and no ventilations. The patient is clinically dead, so there are no interventions.

 

[DailyBread]

Your fears have mainly been based on anecdotal evidence, but I do not understand how you can make general assumptions about all medical teams or units and that they maliciously seek to stop all care (please offer statistica data that proves your point because I am sure many like this paramedic offer stories where what you report is not the case at all). It is unethical and all cases of that should be reported. It is acceptable to sign DNR orders because chest resucitation can be very violent… ribs are broken with risk of causing punctured lungs and other internal organs leading to internal bleeding. It is a risky procedure that can have more harm than good especially end of care patients. Something like only 30% of patients who recieve CPR ever live to be discharged (meaning they die days to weeks later) and those that do, a very few especially those who are terminal or very elderly live much past that. A No Code is only for CPR and it is taught that to not do other care is unethical (the system is not set up to get the little guy). I am sorry if you have had bad experiences in your life and it is understandable why you fear DNR orders, but please do not throw blanket accusitory statements that indict all of medicine as guilty of this when I believe it is not the case.

 

[etbbcpp]

This is a great post. I am on a committee at my(Catholic) hospital and we are making some changes to our DNR orders. One thing that is extremley misunderstood is that these directives only go into place when resperations or heart rythms have ceased. Up until that point it is expected that all care be provided. It is perfectly reasonable to have healthy people who are trying to recover choose to be “DNR.”
The language is changing a bit as well. DNAR, Do Not Attempt Rescucitation is a better phrase. As an earlier post mentioned, the survival rate after heroic measures is quite low. It can be violent with broken ribs, punctured lungs, etc. That is rare. Shocking the heart is VERY painful. The line that has to be found is the one where we are no longer prolonging life but prolonging dying.

 

[Traditional_Ang]

May God be with you!

Food and water are basic requirements to my understanding. My Grandmother (Nana) had hospice at the end in my Mom’s home. She died peacefully after several days. She was kept on pain medication but she got to the point where she no longer wanted to eat and her body just started shutting down. She was 94.

May God rest her Soul,

God bless you,

Donna:

May your Nana rest in peace. The following is from a prayer one of the Orthodox brothers sent me a day after Theresa Schindler Schiavo died.

IKOS 11

The dead will rise and those who are in the graves will stand up, and those who are alive on earth will exult when they stand with their spiritual bodies, radiantly glorious and incorrupt. Dry bones, hear the word of the Lord: “I will bring upon you a spirit of life, and will lay sinews upon you; and I will bring flesh upon you, and cover you with skin.” Rise out of the ancient past, you who are redeemed by the Blood of the Son of God, restored to life by His death, for the light of the Resurrection has dawned upon you. Open to them now, O Lord, the whole abyss of Thy perfections. Thou hast shone upon them with the light of the sun and moon, that they may see the glory of the radiant choirs of Angels, Thou hast delighted them with the magnificence of the heavenly lights of East and West, that they may also see the never-setting light of Thy Divinity.
O Lord of unutterable Love, remember Thy servants who have fallen asleep.

users.sisqtel.net/williams/akathist-repose.html

Last year, I was at the bedside of a man who died pretty much in the manner of your Nana. He and he daughters had to struggle to get him home from the convalescent hospital, where after a few good weeks of enjoying his house, he died.

I seem to recall that nutrition and hydration weren’t removed until it was obvious that he was dying.

Your Brother in Christ, Michael

 

[paramedicgirl]

Your fears have mainly been based on anecdotal evidence, but I do not understand how you can make general assumptions about all medical teams or units and that they maliciously seek to stop all care (please offer statistica data that proves your point because I am sure many like this paramedic offer stories where what you report is not the case at all). It is unethical and all cases of that should be reported. It is acceptable to sign DNR orders because chest resucitation can be very violent… ribs are broken with risk of causing punctured lungs and other internal organs leading to internal bleeding. It is a risky procedure that can have more harm than good especially end of care patients. Something like only 30% of patients who recieve CPR ever live to be discharged (meaning they die days to weeks later) and those that do, a very few especially those who are terminal or very elderly live much past that. A No Code is only for CPR and it is taught that to not do other care is unethical (the system is not set up to get the little guy). I am sorry if you have had bad experiences in your life and it is understandable why you fear DNR orders, but please do not throw blanket accusitory statements that indict all of medicine as guilty of this when I believe it is not the case.

Our ambulance service is currently involved in a North American study for early defibrilation. It is actually Seattle who has the highest survival rate for cardiac arrest patients. That rate is 19%, which the rest of us are hoping to emulate with the results of our study.

And yes, every time I do CPR, I break a patient’s ribs. It’s not often we bring back a viable pulse, either. We pretty much would have to be on scene with a defibrilator at the moment of collapse for the patient to have a good chance of survival.