Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

What is a DNR and why do they cause so many problems?

The comment section of my previous post, A Spoken DNR – Should EMS Honor It?, includes a question by Bamalaura. The reply requires more than a comment.

Bamalaura,

You suggested that I be gentle in my reply. The criticisms I include are not of you. You ask questions that are sensible, but the final drafts of DNR rules seem not to have considered some sensible questions. Each state in the US has different DNR rules. I think New Jersey was the last state to allow DNRs about two decades ago. Outside of the US I don’t know how things are handled. So, the examples I give may not have much to do with the DNR rules where you live.

You bring up a lot of important questions, so I am answering them as a separate post, rather than as a very long comment. I already responded to Vince in the comments, so you might wish to read that, as well.

DNR = Do Not Resuscitate, some places use variations on this, such as DNAR (A = Attempt).

POA = Power Of Attorney, and there are plenty of variations on this.

The question about carrying blank DNR forms is interesting and expands on what I wrote. The DNR/prehospital DNR/living will/advance directive/ medical POA is, ideally, supposed to be written at a time when the patient’s life is not in immediate jeopardy. This is so that the patient is less likely to make a rash decision. The decision is supposed to be one that is based on a full understanding of the risks and benefits of attempted resuscitation (or of specific interventions, e.g. intubation, blood transfusion, antibiotics, …). If the patient does not have the capacity to make an informed decision about this, then the guardian (often a close relative, but sometimes someone appointed by a court) is supposed to make this decision before the immediate need for treatment arrives, so that the decision is informed and not rushed.

The avoidance of pressure to make a bad decision now is one of the reasons EMS does not carry DNRs. EMS is prejudiced toward treatment. We are taught that if there is any doubt – ignore the patient’s wishes.

Many non-medical people have very little idea of what is involved in the various treatments that may extend their lives (or extending their deaths, depending on how full the glass is). As they gain more knowledge, such as by being intubated, they may change their perception of the acceptability of different methods of delaying death. They also may have more of an understanding than the medical personnel of these risks and benefits that they face in refusing care.

Many medical people tend to dismiss the patient’s input automatically as uninformed or due to hypoxia and, with no small amount of hubris, overrule the patient’s decision.

There are three ways that I see this.

1. “The patient is hypoxic, so we cannot pay any attention to the patient’s wishes.” Nothing is done to determine the patient’s capacity to make a decision, but it is disregarded as a byproduct of hypoxia.

2. “We don’t know what the outcome of this illness/injury will be, so it would be wrong to treat the patient according to the DNR and possibly be sued.” Actual comment (paraphrased, I was not taking notes at the time) from an actual board certified attending emergency physician, but his brother is a lawyer, so he dispenses legal advice.

3. “Let’s see what the patient wants. If we can scare the patient into making any kind of statement that could possibly be interpreted as wanting to live, or wanting to breathe, or not being happy with his current health, then we have the authority to state that the patient revoked the DNR and is entitled to all of the care that we have available to us.” This approach is one that does not consider the role that hypoxia, or dementia, or anything else might play in altering the patient’s capacity to make an informed decision.

Why is the deck stacked so heavily against the patient making an informed decision to refuse care?

Do religions prohibit DNRs?

No, most religions believe in an afterlife where the devout are experiencing a more ideal existence, not weighed down by physical impairments, unless they are going to a bad place. A refusal to allow a patient to die might be interpreted in the opposite way – why are you interfering with God’s plan? This is not the typical view expressed by religions. Instead they tend toward the “No heroic (extraordinary) measures need to be taken by the devout to avoid meeting their maker.”

In my opinion, the main reasons that DNRs are such a cluster is that people spend as little time as possible thinking about things that are “unpleasant.” Many people do not have wills, so they are stating that they think the government will do a better job of deciding who gets their belongings than they would.

When a patient is in a nursing home they may have a DNR. Unfortunately, most of the DNRs I have seen from nursing homes are NOT prehospital DNRs. In the state where I most often work, these DNRs are useless outside of the hospital. An original – not a copy – prehospital DNR is the only documentation that may be accepted by EMS. We are more concerned about a murderer, who has failed to kill his intended victim, but is able to compose a passable copy of a prehospital DNR, and not an original of this form. This thinking surely has its own little place in the DSM IV. “We’re from the government and we’re here to help.”

What good is having a DNR that is only good in a hospital, when you are not in the hospital?

If you are having respiratory distress, reside in a nursing home, and need to get to the hospital, how do you expect to get there?

EMS.

Who are the only people who cannot follow the standard DNR, where I work?

EMS.

Who makes these decisions?

Committees – organizations designed to dilute and deflect responsibility for their own decisions.

Sadly, this is one of the places where Americans seem to be hard at work outlawing responsibility.

Bamalaura, you also asks about how refusal of care is handled, since most people understand that adults, who have the capacity to understand the risks and benefits of the proposed care, may refuse that care.

Refusal of care is not supposed to be all-or-nothing. This interpretation by medical personnel is not something that should be encouraged, but it does happen. You may accept some treatment, but refuse transport; you may accept transport, but refuse treatment; you may accept some treatments and refuse other treatments and refuse transport; you may accept some treatments and refuse other treatments and accept transport; you may refuse all treatment and transport. Regardless of your treatment/transport decision you may call 911 (or whatever emergency number is used where you are) at any time and still have all of the same options.

If you were to sprain your ankle while jogging, few people would consider this a life threatening condition, so your refusal of care is often treated much differently from a refusal that allows the patient to die. Your ankle injury potentially presents threats to life or limb, but these are rarely the outcome. Not so much concern for an irreversible outcome (death due to a blood clot or permanent disability due to improper management of the injury are two examples of possible bad outcomes). If you are experiencing difficulty breathing and have a serious, possibly terminal, medical condition – the outcome is much more likely to be one that is irreversible.

Elizabeth Kubler-Ross wrote On Death & Dying about our difficulties dealing with death in 1969. We do not seem to have progressed much since then in accepting our mortality.

Babs writes that the patient should have a living will and that this is more important than a DNR. Where I am, this is not the case. We may not honor a living will – only a prehospital DNR.

GuitarGirlRN writes that treating a competent person against their wishes can be assault. I agree that it should be something to consider, but the state tells me that the EMS rules that I operate under outrank the criminal law. Why have ethics when you have no accountability?

The simple way to deal with anything other than a prehospital DNR is to contact medical command for permission to treat the patient according to the patient’s wishes; tell medical command what evidence there is of these wishes actually reflecting an informed refusal; hope for the best.

I have not had a medical command doctor order me to treat a patient against the patient’s wishes, whether living will, POA, or other form of advance directive.

Comments

  1. I suppose I did respond from the point of view of the provider. I was trying to answer the question of “what would you(provider) do?”.What is best for the patient? I firmly believe that patient autonomy must be the overriding principle governing all care. With certain exceptions revolving around capacity and competency (setting down those guidelines can be quite complicated in and of itself) patients as you correctly point out do have the right to chose their health care a-la-carte. I think it is important to differentiate between a DNR, which only becomes relevant in the event of a code situation, and other forms of advance directives (I don’t want an IV etc.) A DNR doesn’t come into play UNTIL and UNLESS the patient has coded. This is a critical distinction. Just because someone has taken the time to say “I don’t want to be resuscitated doesn’t mean we withhold care that may stave off the code. The idea of a blank DNR form in the field is ridiculous in my opinion. The process to draft cumbersome for a couple of reasons. Not least among these is the absolute finality of the decision. (Even with a valid, signed DNR in place the patient can change their mind.) It is necessary for the physician to explain all of the options of treatment the likely side effects or outcomes of accepting or refusing a particular treatment; and only armed with this information can an informed decision be made. This is not and should never be the role of an EMS provider. I think that most people want to believe we as EMS professionals will do everything we can to “save their life”. In the event that a person feels so strongly about not being resuscitated they should secure the necessary paperwork. As unfortunate as it is, we live in a very litigious society and this kind of liability is best left a few pay grades up so to speak. But as you stated this is not necessarily best for the patient. How do we remedy this?I suppose education about what a DNR is and what advance directives are- would be a start, as well as making the distinction between the typical DNR and a DNR that pre-hospital providers can recognize.

  2. Thank you, Rogue Medic, and everyone else too. This subject gives much food for thought, from the patient/family angle (mostly). I do not have the fear of death that I once had, after helping the RN to provide in home hospice care for my dad. I am grateful that he had the time, sensibility, and forethought to make his wishes known. It made things much easier for all involved.I guess maybe that is the key. People need to lose the fear of talking about death and address their wishes in advance, no matter what their age may be. It is disconcerting that every state has different laws, so that my mom’s signed DNR/POA/whatever may not be recognized if she is visiting another state (different form, something missing or worded differently, etc).Yet another question…if a DNR only comes into play only WHEN and IF a patient has coded, how would a patient “change their mind?” Maybe I am misunderstanding somthing (it’s been a long and insanely crazy day), but I assume that a patient that has coded is unconscious?(and thank you all for being gentle to this typically quiet lurker)

  3. Allow me to clarify. Yes, you are correct that when a patient codes he is indeed, unconscious. What I meant to say was that if a patient is in the hospital with a valid signed DNR order and starts to decompensate and prior to loosing consciousness and/or codes utters, “Please save me.” then this of course supersedes his DNR order. In essence he has changed his mind. I hope this clears up what I was trying to say. Furthermore, you needen’t ask for gentile treatment on this blog. I suspect Rogue Medic can barely spell sarcasm, yet alone have proclivities toward such behavior.Wink wink nod nod!

  4. “Maybe I am misunderstanding somthing (it’s been a long and insanely crazy day), but I assume that a patient that has coded is unconscious?”Quite often, families ignore the DNR wishes of their loved ones.In my experience, the doctors usually bow to the family’s will, because a dead patient can’t sue, but a live and angry family member can.Mark my words – one day there will be a successful lawsuit for wrongful resuscitation, and we will see a sea change in attitudes toward honoring (or not honoring) DNR orders.

  5. Mark my words – one day there will be a successful lawsuit for wrongful resuscitation, and we will see a sea change in attitudes toward honoring (or not honoring) DNR orders.Of course, this will open the door for lawyers to pursue “wrongful parturition” suits.

  6. “Quite often, families ignore the DNR wishes of their loved ones.In my experience, the doctors usually bow to the family’s will, because a dead patient can’t sue, but a live and angry family member can.”I was shocked to read this! How could a family do that to a loved one? Would you assume there is a lack of communication…dad never told son about dad’s DNR…or is it more self-serving reasons??Given this reality, I would love to see a wrongful resuscitation case. It kind of seems inevitable…(PS – I learned a new word today…parturition…the process of human childbirth) Thanks, Vince! ;o)

  7. bamalaura, Vince can teach you all sorts of interesting things. :-)As far as families acting against the wishes of another family member – it happens all of the time. Besides, now that the family member is quiet there will be fewer arguements and more togetherness. While I say that with some silliness, I do see that as part of the motivation – “Now we can have a peaceful meal together,” one through a feeding tube and the rest in the conventional way.There is also the belief that they will have a miracle return from the dead. Unfortunately, there is a lot to reinforce these foolish beliefs.Recently CNN had a segment “Brain-dead baby recovers.” The story described a baby that was resuscitated quickly and with a good outcome. The baby had been clinically dead, but far from brain dead. This irresponsible reporting leads to all sorts of excesses in the belief that their family member will recover. Brain dead means one of two things – an intact corpse or an organ donor. The organ donor at least helps those who have a chance at continuing to live.http://www.cnn.com/video/#/video/us/2008/02/22/lazar.miracle.baby.KCAL?iref=videosearch