DNR 101

Over the last year or so during the health care debate, thanks to politicians’ and pundits’ hysterical fear-mongering, Do-Not-Resuscitate (DNR) orders, along with other advance directives used in health care, took a few steps back in its vain quest for a little bit of respect and recognition from the general public. Besides, how can we expect the general public to understand a DNR when even doctors and nurses don’t understand it? And how can we even try to show people the facts when there are people out there deliberately distorting end-of-life issues?

On a related note, why is it OK to put our pets down to end their suffering but somehow it’s automatically and unequivocally wrong, as some claim, to do the same for our family members?

Put in the simplest terms, with a valid DNR, a patient without spontaneous breathing or a pulse is not resuscitated; in other words, we “let them go.” A DNR is only valid if the patient is pulseless or apneic; it is meaningless otherwise.

Many providers mistakenly view a DNR as an excuse to not initiate treatment, even treatment as simple as fluids or relieving an airway obstruction. That is very wrong.

Some patients actually think we will smother them with a pillow if they have a DNR (I’m not making this up) but that cannot be farther than the truth. Many patients who should at least consider getting a DNR don’t get one. I’m not saying everyone should get one, but many people don’t even want to think about and plan in advance their end-of-life decisions, and that is foolish.

As I’ve mentioned before, primary-care physicians have to bear a lot of responsibility for this phenomenon. If I have to explain advance directives to someone on a call, it is way too late. These days I’ve been actively trying to discuss end-of-life issues with certain still-living patients and their families whenever the appropriate opportunity arises.

How many times do we go to a cardiac arrest call only to have the family beg us not to start the resuscitation (“That’s not what my grandmother wants!”) but they don’t have any paperwork declaring those wishes?

How many times do we go to the same call only to have everyone fighting over what the patient’s wishes actually were, also without any paperwork declaring such wishes?

How many times do we go to the same call only to find that nobody has any idea where the valid DNR form is in the house?

How many times have you seen a family member, for his or her own selfish reasons, insist on a resuscitation over the objections of everybody else on the scene?

You think MCIs are dramatic? Try these scenes I just mentioned.

The simple fact is this: get your paperwork in order, and we will respect your wishes no matter what your wishes are.

All we’re asking for is the following:

  • please, please, please think long and hard about what your end-of-life choices are
  • discuss them clearly and intelligently with your family
  • make them understand the importance of respecting your wishes
  • put these wishes on paper

And, for those who haven’t seen this: the POLST form, sort of a “DNR on steroids.”

One thought on “DNR 101”

  1. I never realized I was so fortunate to live in an area where POLST forms are the “standard of care.” We even have an electronic POLST registry; if we have a patient who we suspect has a POLST but doesn’t have the paperwork, we can call the registry, provide patient info, and find out what their orders are. It’s a good system.

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