When I wrote last about talking with the family members of COVID patients admitted to the hospital, I received a lot of questions about two topics - medical care at the end of life and DNR orders.
The time of COVID-19 has had many of us thinking about our end of life wishes a lot earlier than we ever would have under normal circumstances. The goal of this installment of my newsletter is to help provide some context for these personal and challenging discussions for you, a patient or patient’s family member.
If this information is interesting, please let me know as there is a lot to expand on for topics addressed here. This an introduction, not a comprehensive guide.
If you’re ever admitted to the hospital, you’re going to be asked about something called “code status” by the doctors and nurses taking care of you. The questions they ask you usually something like, “if your heart stops and you need chest compressions, would you want us to do them?” or “would you want a breathing tube placed if you couldn’t breathe on your own?”
Why are they asking me these questions?
These questions are asked of every person who gets admitted to the hospital and the answers that you give end up in the chart in one of two categories: DNR/DNI or Full Code.
DNR stands for “do not resuscitate” and DNI stands for “do not intubate.” Resuscitation means that if your heart stops beating, doctors and nurses perform chest compressions and give medications like epinephrine (adrenaline) in an attempt to restart the heart. Intubation means you are placed on a ventilator, when a breathing tube placed through your mouth into your lungs to breath for you.
Full code means, “if my heart stops, I want the medical staff to perform chest compressions on me and place a breathing tube no matter what else might be going on with my medical care.”
DNR doesn’t mean Do Not Treat.
Full code doesn’t mean you’re going to survive CPR or come out of successful CPR and get back to normal.
DNR is the wrong thing to focus on
These are important questions, but they aren’t the right first questions to be asking. Most of the time, this discussion isn’t done in an appropriate context, and when these questions are asked out of context, the discussion can be pointless, or, even worse, end with feelings of antagonism from patients and their families toward the medical staff.
It can feel like the staff is asking you, “can we just stop treatment now because you’re going to die anyway?” But that’s not what these questions are really about. The question about DNR is really the end of the conversation, not the beginning.
The medical team is required to ask these questions of patients admitted to the hospital. It isn’t a tip off that your doctor thinks you’re going to die or will need these interventions.
In order to make a decision about chest compressions, you need to understand the medical context of these situations.
What do you mean about medical context?
Ultimately, making a decision about DNR or full code often boils down to willingness to suffer through a prolonged recovery.
Patients who have a cardiac arrest in the hospital do really poorly. This may seem obvious, but it is vital to emphasize. In most cases, an in hospital cardiac arrest is a marker of how sick someone is, rather than being an unrelated and easily treatable problem.
If your heart stops in the hospital, you have about a 10-15% chance of leaving the hospital alive.
Your chance of going straight home is much lower than this. In other words, even if you are in the 10-15% who survive until hospital discharge, it’s likely that you are still looking at months of slow, painful recovery with an unclear probability of independent living.
Ultimately, it really boils down to what I think is the most important question to answer when you’re thinking about DNR status:
Is a long nursing home stay with uncertain chance of full recovery something that you - or your mom, or your dad, or your husband/wife - would want because it means more time on Earth coupled with a possibility (however remote) of getting back to normal?
If the answer to the question is clearly yes, then you want to be full code.
If the answer is clearly no, you want to be DNR.
If the answer is that you aren’t sure, then thinking about the context becomes helpful.
Someone admitted to the hospital with a minor heart attack has a different likelihood of recovery than someone with a huge heart attack complicated by congestive heart failure or cardiogenic shock.
A COVID patient receiving supplemental oxygen has a different prognosis than one on a ventilator with kidney failure.
An 89 year old from an assisted living facility has a worse prognosis than a 55 year old who is working full time even if they come in with the same illness.
What else should I be considering?
You should be thinking about frailty.
Frailty is the most important part of a patient’s clinical status that doctors often don’t adequately address.
Frail patients are the ones least likely to recover and most likely to suffer.
Frail patients are the ones who don’t ever get back to normal even when they’re admitted to the hospital for a short period of time with a completely treatable illness.
Frailty plays a bigger role in prognosis than the presence or absence of any comorbid medical condition.
In many cases, consideration of frailty seems intuitive but ends up elusive. As we think about the goals of medical care for ourselves and our loved ones, it’s the most important factor that I wish we would all keep in mind.
I was wondering if, with the dismal likelihood of response to CPR in Covid and the real danger of contagion when administering CPR to a patient, if it is ethically justifiable offer it, and if not, then it is not a question of asking about DNR, but rather a discussion of why that will not be offered. Tom Reagan