I know that it sounds like the classic FDGB (Fall Down Go Boom!) syndrome, bu in my eyes, it’s something different. I’m talking about DNR status. Lately some of docs, most notably residents, have been writing rather bizarre and oft-times confusing DNR orders. Our DNR sheet has four sections. First, is “Full Code,” simple, classic and easy. Second, is “Do Not Resuscitate, no interventions, comfort care only, let them pass in peace. Third is “DNR with Limited Interventions” meaning no extreme measures, no transfers, but not just leave them be. Finally there is my favorite, “DNR with Advanced Interventions.” A fine catch-all that allows the docs and patients to fine-tune exactly how much we can do. And does it every get creative from there. Here’s a fine selection:
“Defibrillation OK, No intubation, vasopressors and antiarryhmatics OK, CPR for 2 minutes.”
You had better choose your drugs quick ’cause you only have 2 minutes to get them into circulation. Hmmm…what’s that? ACLS guidelines? Right, we don’t even give drugs until at least a round of CPR has been done . So we burned up our CPR and really who is paying attention to time in a code? We’d going hell-bent for leather and someone will pop up and say, “Oh, minutes are up.” It wold be like when you’re walking someon with nasal cannula on and they run out of tether, you get that jerk back, where their head snaps back and they’re pulled up short like a fish on a hook.
“No defibrillation, no intubation, no CPR, vasopressors and antiarrythmatics OK.”
Hence why I call it a gravity code. Push the drugs in, give it a good 20ml saline flush and hold that extremity up in the air and let gravity get the drugs into circulation. Seems like it would work fine. Maybe do a little massage to puch it down the vein back towards the heart while you’re at it. Kind of like external counter-pulsation…technically it’s not CPR. I mean who cares that we have to overcome capillary pressure, much less bridge the gap from that antecubital IV site to the heart and then into circulation.
“CPR OK, no drugs no defibrillation, no intubation.”
Right, so we have nothing to shock the heart back to an organized rhythm. Studies (which I’m not going to go Google now) have shown that electricity is the best treatment after good CPR in event of a cardiac arrest. The American Heart Association considers this top-tier evidence based practice, and adjusted the algorithms for VT and VF to include a shock quickly after start of he event. Sure, we can perfuse the body with CPR, but if the heart is acting all crazy and not maintaining an adequate perfusing rhythm, all that CPR will do for naught when you stop. Maybe in cases like this we should all line up and yell, “BOO!” at the heart in order to shock it back to rhythm. I can hear it now:
Team Leader: OK, let’s have a rhythm check. Still Vfib? OK, I want a verbal shock…who’s turn is it?”
It would be like the scene in Airplane where we’re all be lined up yelling at the chest, “Get ahold of youself…”
Again, doesn’t seem all that effective.
Finally, my favorite. Wait for it…
Yes. You read that right. Ask. The. Patient. In the middle of a code. When technically they’re dead. I’m sure that’s going to work very well.
“Umm…excuse me sir. Even though you’re unresponsive, have no pulse and are not breathing, per your DNR orders do you want us to code you?”
Let’s just say the resident and the attending had a long discussion about the appropriateness of their orders.
I know that it stems from the worry that by being a DNR it means we won’t treat the problem. DNR does not mean Do Not Treat. Infact, we will do what we can to avoid a code situation. It also stems from the belief in American society that death is not a natural extension of life, but something to be avoided. And by declaring you’re a full code it means that you (or your family that it wracked by feelings of guilt for their mistreatment of you) are not going to give in the Reaper. Even it that means spending your last days intubated, on multiple pressors, being fed through a tube, in pain from cracked ribs earned in the massive code, in renal failure on CVVH and never regaining consciousness to talk and explain your wishes to your family. It’s the lack of understanding that death is as much of a a part of life as birth is. But with the prevailing dream of living forever coupled to classic American arrogance has led to a multitude of ridiculous and untenable wishes. We don’t want to die because we cannot accept that we can’t be fixed. We don’t want to leave our families. But in this denial of death, we leave our families in a lurch, left adrift and controlled by their own emotions on how to proceed. Unless you put your wishes in writing, we will do everything we can.
I leave with a contrast.
Case A, younger, but with end-stage CHF due to a life of hard living. Coded for 40+ minutes, multiple attempts at intubation, central line placed, labs, 2 shocks, 30+ minutes of CPR, 3/4 of all the drugs in the code cart and never maintained a pulse and never woke up. Traumatic, intense and in the end still despite our best efforts died.
Case B, end-stage COPD, DNR on supportive and comfort measures, i.e. morphine, oxygen, eating what they wanted, found on early rounds dead. They had passed peacefully in the night, quietly, without trauma, calmly but the end result was the same. We knew whe was going, it was just a matter of time. Family had accepted it, they accepted it and we as staff accepted it.
Which on was better? I know where I stand.