Listen, you might not want to think about it but it’s best you get your wishes settled BEFORE you are on death’s door. Once you get over 65 it’s best to spell things out in clear language. I am talking about end of life care – and I mean you need details. What do I mean? Well, since there is no standardization across states, hospitals, nursing homes, etc, you need to spll out clearly what you want done when you are going down the tubes. For example,
1). DNR – means “Do Not Resuscitate” – but there is not an official definition of this. It is generally taken to mean if one’s heart stops, you don’t try to restart it. But there is more to it than that. Do you want everything possible done up until that point? Besides no CPR and Defibrillation, what else don’t you want? Meds? IVF? Pressors?
2). DNI – means “Do Not Intubate” – that is pretty straightforward. Don’t tube me and put me on a vent. However, some people take DNI to be part of DNR – thus it may be assumed if you are DNR that you are also DNI. Other times, you might want to be DNI but since it was not specifically spelled out on your paperwork, you might get tubed even though you are not in full arrest – and you might not want that.
3). DNT or DNH – “Do not Transfer or Don Not Hospitalize” – usually part of a hospice situation however you theoretically can be DNT but not DNR or DNI (some nursing homes can handle vented patients) . Spell it out!
4). Palliative Care Only- in addition to DNR and DNI, palliative care is only to make someone comfortable and not to try to cure or stabilize anything. Theoretically you can be palliative care only but not be DNT or DNH.
Basically, have your lawyer spell it out so medical staff (and especially EMS) can easily know what you want and don’t want. Have you health care proxy’s cell phone number on the paper so they can be called in an emergency. Tell us you don’t want to be defibrillated or have your chest compressed but since you are not a vegetable and just have bad CHF, you would accept a temporary intubation until you get diruesed. Also, make sure your health care proxy is not a nut job. Not only should they understand your wishes but they have to be sane and not a nightmare for health care professionals to deal with. Chose well.
Otherwise you risk either being allowed to die against your wishes or NOT being allowed to die against your wishes!
In Scotland the equivalent of DNR is called DNACPR which stands for do not attempt CPR and that is ALL it means. No CPR. It doesn’t cover any other intervention at all. I quite like the specificness of it.
Someone i had durable power of atty for rescitated her even though we had everything spelled out and notarized because the doc claimed to not know what power of atty was. She lived two more unwanted years until eventually i had to take ber off everything. Your tax dollars at work! My father similarly got rescitated with a dnr and we had to remove him from life support. None of these documents help with docs that either dont read the chart or dont want to feel reslonsible.
Grrrr…
No doubt you’re a frustrated ER Doc, but how are us mere patient morons supposed to know that our lawyer who drafted our DNR, Medical POA, and whatnot, was a moron, or our next-of-kin aren’t going to pull a 180?
What’s your solution, doc?
Maybe a sub-dermal microchip encoded with all of the information. EMTs scan: they know how far to go..ie keep me breathing long enough to harvest organs or just roll me in so I can get called a DOA.
Apologies for the vitriol in my last post – I was being a typical web idiot and managed to hit “submit” before thinking about it and editing….
The problem is, your qualifications for what really constitutes specific medical end-of-life wishes are not anywhere close to common knowledge – and I’m sure a lot of your patients don’t have any kind of paperwork expressing even basic DNR stuff, never mind paying the fees to have a lawyer draft one up. And even then your average layman can’t be sure that whatever the lawyer came up with is up to snuff.
It’s just a mess.
This has particular significance for those of us who live with severe disabilities – we are the most likely group outside the demented elderly who are at significant risk of someone deciding to make us DNI or DNAR (England’s term – do not *attempt* resuscitation, which I rather like) against our wishes, motivated – I can only assume – by an entirely mistaken confusion between functional impairments and quality of life.
If I’m happy at MY baseline (which, yes, includes a PEG and 24-hour care), and there’s a reasonable prospect of my returning to it, or indeed to any other state in which I am still able to enjoy rude jokes and the company of my loved ones – then I want that chance.
A colleague with severe-ish spinal muscular atrophy (breathes unassisted but things get a bit marginal with a bad respiratory infection) was in hospital having treatment for a chest infection when she heard the admitting doctor inform the incoming shift that “the lady in bed 8 isn’t for intubation”. She was so frightened that she kept herself awake for the next 36 hours.
What happens if a patient has their i’s dotted and t’s crossed, and their kids start crying and say do everything?
advice on these difficult decisions was meant to be part of health care law, and was labeled as death panels, just like major potential cost savings were called cuts in service.
Sometimes it’s hard to see that these things are followed, in the heat of the moment, so to speak.
My mother has a DNR order. A couple of years ago she ended up in a minor fenderbender. Went to the ER, was put on Oxygen, and seemed stable so I went home to get some sleep.
She coded about two hours later, there in the ER. Through a series of miscommunications, her DNR was not followed and she got CPR and was brought back.
It worked out for her: she’s recovered to the high ninetieth percentile of her pre-event condition. And I’m profoundly grateful for that. But it’s also emphasized how important communications about this is, even if you don’t think it’s necessary, right from the beginning.
I really like Tennessee’s advance directive form, very clear:
http://health.state.tn.us/AdvanceDirectives/Advance_Care_Plan.pdf
Not sure if other states have similar forms, or if someone could use TN’s form even if they don’t live there.
In nursing school we were taught about Five Wishes. Its suppose to make this task less overwhelming.
http://www.agingwithdignity.org/five-wishes.php/