The Thing About DNRs

Saturday, March 29, 2008

DNR means Do Not Resuscitate. It's a term people in healthcare are very familiar with, as are those of us with terminally ill family members or friends.

I had my mind blown (again) a couple of days ago at work when the difference between hospital and prehospital once again became staggeringly obvious.

Imagine you have a patient in a truly terrible heart rhythm that while not immediately fatal, isn't sustainable (those of you who are medical - we're talking third degree block, rate of 20). The patient is alert, oriented, and has a DNR. You explain to him that you aren't supposed to give him drugs or electricity, that your mandate extends simply to palliative care. Imagine that he's at peace with that.

Have I lost you? Here's what the state of South Carolina has to say about it:

"...(EMS personnel) Upon finding an unaltered EMS DNR Form, will withhold or withdraw resuscitative measures such as CPR, endotracheal intubation or other advanced airway management, artificial ventilation, defibrillation, cardiac resuscitation medication and related procedures.

Will provide palliative and supportive treatment such as suctioning the
airway, administration of oxygen, control bleeding, provision of pain and non-cardiac medications, provide comfort care and provide emotional support for the patient and the patient’s family...."

We understand the part about no cardiac meds and no resuscitative measures, right? And yes, that includes transcutaneous pacing. Your treatment is pretty much limited to high flow oxygen, Trendelenburg (lie them flat on their back with their feet propped up - helps bring up a low blood pressure), and fluids.

Now imagine you get to the hospital, and are welcomed with comments like "Well, didn't you give atropine?" and "I don't know why people with DNRs want to come to the hospital, because then we have to treat them." Then the patient is quickly administered the same meds that I withheld (in accordance with DNR laws and his personal wishes) while his pleas that he needs to pee are ignored (another aside for the medical people - no, atropine *still* doesn't work on high degree heart blocks).

This being EMS, I don't know how the story really ends. I do know that his family got there in time to explain his wishes in a louder voice than he was capable of, and I also know that in addition to a DNR he also had a living will/advance directives.

I understand that Do Not Resuscitate does not equal Do Not Treat. It means do what you can, and keep them comfortable until you can get them to a higher standard of care. I don't understand why often ER staff can't take a moment to read some paperwork, listen to their patient (and their patient's medic), and respect someone's wishes. That's why people pay lawyers lots of money to write things like living wills. You don't *have* to treat them. You *should* put yourself in their shoes and ask "Would they really want this?"

Experiences like this make me very nervous, and hopeful that the staff at the hospitals in Ottawa are a little better about reading DNRs than they are here. After all, my mother lives in a nursing home in Ottawa, and she can't speak for herself - her DNR has to speak for her.

All I'm hoping for is a little *thought* from the medical people.