I have seen DNR sold to patients and families with the phrase "DNR doesn't mean do not treat" and time and again once the DNR is in place many potentially effective interventions are suddenly out of the question. DNR/DNI if sold this way is not comfort care. I recall a patient at an acute facility where I used to work prn. I was sure if I could get him in the LTAC where I also worked and had some time he would do very well. He was resp. failure with COPD and CHF as the primary underlying issues which made intubation and ventilation a requirement. The patient was not a candidate for discharge to LTAC due to funding issues and had outlived his DRG in the acute ICU. This alert patient had significant setting decreases during the last shift which I cared for him. Based on this I had been very optimistic with him and his family about potential progress. A nephrologist had been consulted and his assessment was that the patient required dialysis in order to continue. It looked to me the social services/case management staff saw their opportunity to minimize losses, gathered the family and specialists in a room and sold the family on the fact that with his multisystem failure he would never improve and that they should make a decision. They did, he was made DNR. That rapidly advanced to "ventilation as an intervention is futile". He was extubated on the next shift and expired the next day. I have seen DNR patients who were not at the point of comfort care, but interventions were withheld as if they were. I don't see the sense of prolonging things needlessly when all reasonable hope is lost; it just seems that too frequently the DNR gets pushed this way and the decrease in aggressiveness of care short of resuscitation that occurs is not what was agreed to. When I mentioned my observations on this to some of my peer's responses frequently are if they agreed to the DNR, they were ready to go. If you asked them or their loved ones who are sold the "it doesn't mean do not treat" line if they are ready to call it quits, I doubt that is what they feel they are agreeing to. When is all hope really lost? I have seen several persistently vegetative patients in my career return to full or nearly full function. These cases had one common thread, a family who refused to give up in spite of multiple specialists' advice, and they kept faith in a recovery. I have, however seen similar scenarios result in a prolonged death as well. It is a complex issue that I struggle with. It distresses me both when anyone with a chance of recovery is not given that chance, and to witness the creeping demise of a patient who was an inappropriate full code and advanced treatment couldn't be ended. It just feels sometimes that advocating for the DNR when appropriate might just turn out to be advocating for the relinquishment of their last opportunity for recovery when that is not appropriate. Thanks for any insights.This message has been edited. Last edited by: GaryMefford,
DNR/DNI should not be used for a do not treat. Considerations on what the treatment plan is and what the patient desires should be taken into consideration. For example a patient may not want to be intubated and may refuse dialysis, but want full nutritional support.
I believe it is our professional and ethical duty to obey the desires of our patients. That does not mean that if they are a DNR/DNI put them at the end of the hall and forget about them. I have had some over the years that were DNRs make a full recovery from their admission illness and go home.
The Hypocratic Oath says, "Do no harm", and if we stop all agressive treatment to a DNR/DNI patient we could be doing harm.
Many patients are admitted to the hospital with standing DNR/DNI orders, and yes I would use bipap. If a patients is made "Comfort Care" and is awaiting death, I would not use bipap.
"For example a patient may not want to be intubated and may refuse dialysis, but want full nutritional support."
If a patient needs dialysis and will die without it and refuses it, no I don't believe bipap is appropriate.
Chris Hanson RN, RRT-NPS, CPFT, AE-C
ER Registered Nurse
Grand Junction, Colorado
I have about 6 years palliative care experience in healthcare and personally in my own family. I feel a great amount of education is needed with healthcare workers for the terms: "DNI, DNR, comfort care, what advanced directives are and when they apply, etc." I believe that the aggressiveness of care should not change, just the interventions are different to acheive the different goals.
In the original post there is not alot of mention of what that particular PATIENT wanted.
I, too, have worked in a LTAC and I know that is not how I would chose to live, many people decline dialysis also. It is about the PATIENT'S choice. Advocating for the patient (a RT's job) is all about helping that patient acheive THEIR goals, not the choice we would make for us, or our family. It can be a difficult situation for all.
Lisa RN, RRT
This may be relevant to the discussion, from Critical Care Forum (they have a very reasonable rate for RT's--to subscribe go to www.ccforum.com) Do-not-resuscitate orders, unintended consequences, and the ripple effect
J Claude Hemphill III
Department of Neurology, Room 4M62, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110, USA
Critical Care 2007, 11:121 doi:10.1186/cc5687
The electronic version of this article is the complete one and can be found online at: http://ccforum.com/content/11/2/121
Published 2 March 2007
© 2007 BioMed Central Ltd
Do-not-resuscitate (DNR) orders are commonly implemented in the critical care setting as a prelude to end-of-life care. This is often based on presumed prognosis for favorable outcome and interpretation of patient, family, and even physician wishes. While DNR orders explicitly apply only to an individual patient, the hospital culture and milieu in which DNR orders are implemented could potentially have an overall impact on aggressiveness of care across patients. As illustrated by the example of intracerebral hemorrhage, this may unexpectedly influence outcome even in patients without DNR orders in place.
Improving end-of-life care in the critical care setting has justifiably become an increasing priority . In patients with severe neurological impairment due to stroke, head trauma, hypoxic–ischemic brain injury after cardiac arrest, and other conditions, decisions to limit or withdraw care are often made based on perception of a poor prognosis for functional outcome. The decision to limit care, however, is predicated on the assumption that the prognosis is known and accurate. The possibilities that prognostic inaccuracy early after stroke and head trauma might lead to decisions to limit care and that these care limitations might create 'self-fulfilling prophecies' of poor outcome in individual patients have been considered [2,3]. Is it also possible that a hospital milieu in which care limitation is commonly sought might also influence overall aggressiveness of care for other patients as well?
The 1983 US President's Commission on Deciding to Forgo Life-Sustaining Treatment  stated 'Any DNR policy should ensure that the order not to resuscitate has no implications for any other treatment decisions.' Even so, do-not-resuscitate (DNR) orders are often the first step in a continuum of limitations of care, especially in acutely hospitalized patients . Patients with DNR orders are more likely to die, including those with stroke . Furthermore, the effect of DNR orders is frequently manifested by physicians being more likely to withhold other therapeutic interventions, and even being less likely to institute them in the first place . Considerable variability has also been documented in the use of DNR orders [8,9], which raises the concern that variability in decision-making regarding DNR orders might reflect larger variability in aggressiveness of care that could influence patient outcome irrespective of code status. We sought to begin to address this question using spontaneous intracerebral hemorrhage (ICH) as a case example.
ICH accounts for about 15% of all stroke. With a 30-day mortality rate of about 40% and only about 20% of survivors independent at a year, ICH prognosis is often poor – although prognosis is dependent on a variety of factors such as the Glasgow Coma Scale score on admission, hemorrhage location and size, concurrent intraventricular hemorrhage and hydrocephalus, and patient age [10,11]. As of writing the present article, ICH is also without an approved treatment of proven benefit in reducing mortality and morbidity. This has led to great heterogeneity in ICH care, with approaches ranging from the very aggressive to the nihilistic .
We hypothesized that the rate at which a hospital uses DNR orders within the first 24 hours after ICH influences patient outcome irrespective of other hospital and patient characteristics. Early DNR orders were chosen because this means that one of the very first medical decisions made for an ICH patient was to limit care in some manner.
From a California-wide hospital discharge database, 8,233 ICH patients treated at 234 different hospitals were reviewed. Interestingly, the rate at which a hospital used DNR orders for ICH patients within the first 24 hours independently increased the odds of individual patient death, even after adjusting for numerous patient characteristics (age, race, gender, insurance status, medical comorbidities, mechanical ventilation as a surrogate for coma) and hospital characteristics (number of ICH patients treated, trauma center or rural hospital, teaching hospital, rate of craniotomy for ICH) . Even more importantly, there was an interaction between an individual patient's DNR status and the hospital DNR rate (adjusted for case mix). This means that it not only mattered whether a patient was DNR (within 24 hours of admission), but it mattered in which hospital that patient was of DNR status. Patients with the same DNR status were treated differently in different hospitals, even accounting for other patient and hospital characteristics, and this influenced their outcome. Interestingly, the group of hospitals with the highest early DNR rate (adjusted for case mix) had lower rates of intubation and mechanical ventilation, craniotomy, ventriculostomy, and cerebral angiography for ICH patients. They also had shorter lengths of stay and lower total costs per patient.
What does this information tell us? Are DNR orders in some patients killing other patients? No. What this means is that there is something in the way overall care is delivered in these 'high-DNR' hospitals that is increasing the risk of death in individual patients treated at those hospitals, irrespective of code status. The early DNR rate of the hospital (case mix adjusted) is acting as a proxy for overall aggressiveness of care. Even in the absence of a proven treatment for ICH, nihilism is ineffective.
For severe neurological disorders such as ICH, functional outcome may be even more important than mortality. It is possible that the physicians in high-DNR hospitals are vastly superior at predicting long-term functional outcome within 24 hours of acute stroke than physicians at low-DNR hospitals, thereby sparing patients destined to have a poor functional outcome by allowing them to die during hospitalization. Doubtful. More probably, this represents an overall nihilistic approach that extends to most or perhaps all ICH patients within a specific institution, probably based on the fallibility of attempting to prognosticate too early and too precisely. The ripple effect of an approach that emphasizes early care limitation leads to an overall milieu of nihilism that, perhaps unexpectedly, may influence attitudes of care for patients beyond those with the DNR orders themselves.
So what are we to do? Just instituting a policy prohibiting DNR orders within 24 hours of hospital admission is not the answer. It is not the DNR orders themselves, but it is the care environment that emphasizes high use of early care limitations in patients that are critically ill. This is actually not surprising given that the same physicians and nurses instituting early DNR orders in one patient may be responsible for determining the need for aggressive care in others. Whether these findings extend to other neurological conditions such as traumatic brain injury or non-neurocritical care is not known.
As we increase our emphasis in critical care on end-of-life issues and compassionate palliative care, it is essential not to lose sight of several important principles. Precise prognostication in individual patients remains challenging, especially early after neurological catastrophes such as ICH. An overly nihilistic approach may influence global care, potentially leading to a ripple effect beyond an individual patient. Part of the art of critical care medicine is balancing aggressive care with realistic expectations and avoiding self-fulfilling prophecies of poor outcome. I think our work is still in progress.
DNR = do not resuscitate; ICH = intracerebral hemorrhage.
The authors declare that they have no competing interests.
This article is part of a thematic series on End of life decision making, edited by David Crippen.
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I just posted an article from Critical Care Forum on this issue.
I remember early in my professional career hearing patient's and their families being told "Just because you choose no-code doesn't mean no care". And then see what an ironic hoax that statement was in retrospect. It wasn't no care, but definitely a big bias and practice whereby care was curtailed. A DNR patient whom wants everything done short of responding to an arrest with CPR and intubation is often not placed in ICU even though their precarious situation would otherwise warrant it. Or after deciding on a DNR/DNI status they are taken out of ICU quicker than the trash. A DNR/DNI patient may be wheezing, SOB and actually having an asthma episode. A call or page to an RT new to the patient might often get responses from other RT's such as "don't rush, he's a no code". And so on. Often these patients are placed on Bipap on a floor ward as their clinical condition deteriorates (assuming they aren't designated "comfort care"---and unfortunately often even if they are) and this use of ventilatory life support on a floor ward, when otherwise either a reversal of DNI/DNR or palliative comfort care would be realistic options, leads to suffering for the patient and is a recipe for medical error and legal/license issues. Picture your butt and/or the RN's mounted on a big plaque on the wall.
Often I'll find a DNR/DNI patient, one in whom the mantra is "we're still doing everything", and I ask people "so if this patient were a 17 year old cheerleader whom was injured saving a toddler would she be cared for in this manner and on this floor?". The juxtaposition is obvious.
If I were a patient on an unmonitored ward I might choose to have a DNR/DNI status----I know that if I were to be found "down" that even if I were to be revived I would probably "live on" most likely as a sick parody of my former life, be just a burden, etc. But I also know that such a designation would bias many in terms of the delivery of care.
The problem also escalates as a DNR/DNI patient whom wants everything short of the code done starts to deteriorate. It seems to me that some type of meeting needs to happen--recognizing that a fork in the road decision needs to be faced by all (and why I abhor the imposition of Bipap or NIV in these circumstances). The bell is tolling and a decision towards either comfort care or a reversal of DNR/DNI needs to be entertained. Many places have some form in which the patient can choose various options. I call these papers "Do You Want Fries with Your Care?" and try to suggest they offer the patient a range of the joules they'd like used to defibrillate or cardio-vert. Or I envision sneaking "ECMO" as an option to be checked in the spirit of "it's the patient's choice"--in many countries the ventilator is akin to ECMO.
The flip side to this is that often DNR/DNI/Comfort Care means very deficient care as we don't really have comfort care down in modern hospitals. So some places strap a mask to their patient's face and pretend it's comfort care.