What are the Patient’s Circumstances?
Patient No. 1: John R. is a healthy 70- year-old going into the hospital for a knee replacement. He does not suffer from diabetes, heart disease or high blood pressure. He takes a statin, which controls his cholesterol, but no other medications. His orthopedic surgeon has told him to expect that the procedure to be performed as day surgery with spinal anesthetic rather than general to be administered. John will be asleep throughout although the spinal will block feeling from the belly button down only. Should he sign a Do Not Resuscitate Order (DNR)?
Patient No. 2: Jane M. suffers a cardiac arrest at home. Her husband, Bill, performs Cardiopulmonary Resuscitation (CPR) on her until the ambulance and emergency medical personnel arrive and take over. When Jane is admitted to the emergency room, the doctors inform Bill that she has a 7% chance to live and recover. Jane is in a coma. Jane has signed a medical power of attorney giving Bill the authority to make medical decisions for her. Should Bill sign a DNR for Jane?
Patient No. 3: Agnes G. is an 83 year-old grandmother with metastasized cancer. She has been told she has approximately six months to live. Recently, she has been losing strength and has had difficulty walking without the assistance of a walker. She is hospitalized with pneumonia. Should she sign a DNR?
What is a DNR Order?
A DNR order signed by the physician tells health care providers not to perform CPR. People often speak of “signing a DNR.” What they have really done is sign a document giving the treating physician the authority to issue the order not to resuscitate to the medical caregivers.
There are actually two types of DNR orders. One is in-hospital and another is out-of-hospital with separate forms for each. An out-of-hospital DNR is needed to prevent CPR anywhere care givers are providing treatment outside the hospital, such as in an ambulance or at home.
What is CPR?
CPR is mouth-to-mouth or machine breathing and chest compression to restore heart and lung function when the heart is not beating or breathing has stopped. Advanced CPR can involve intubation (the insertion of a tube into the mouth or nose to assist breathing), mechanical ventilation (a machine to move air into the lungs), medication given intravenously to control blood pressure, heart rhythm or blood flow or cardioversion (electrical shock to change heart rhythm.). The chest compression requires a great deal of force, so there can be injury - such as broken ribs - to the surrounding area.
These emergency procedures are not always successful and present risks. They frequently do not work with those who have widespread cancer, widespread infection, terminal illness or certain other severe health problems.
CPR is sometimes only partially successful. It may restore heart or lung functioning so that the patient survives but with brain damage or with organ impairment requiring permanent dependency upon machinery to breathe. This result occurs especially frequently with the elderly and the very frail.
How Should the Decision be Made?
The particular medical facts involved are primary factors in determining whether to authorize a DNR. For instance, a DNR could be appropriate if the patient has a medical condition which can reasonably be expected to result in imminent death. Another might be if the patient is in a coma or state without cognition combined with no reasonable possibility of regaining cognitive functioning. A DNR would be advisable when the physician concludesbelieves that CPR is not likely to be successful under the circumstances.
The decision to sign a DNR is like any other medical decision. The individual considering one should have a frank conversation with trusted physicians and other health care providers concerning the options for treatment and the advisability of a DNR. In addition, it is helpful to discuss the decision with family and friends. Some will want to seek counseling from their clergy, from therapists or from social workers. The decision is not only a medical one but a psychological and spiritual one as well.
Should the Patients Described Above Sign a DNR?
Patient No. 1: John R. would most likely not want to sign a DNR. He is healthy and has no life-threatening medical issues. His care givers would likely advise him that, even if he had a DNR, and he stopped breathing during surgery, the surgeon would request of the family a suspension of the DNR for at time period, such as six hours or more. This suspension would provide time for intervention that could bring him back to normal functioning.
Patient No. 2: This situation is the trickiest of the three patients described. Jane M.’s husband should discuss the situation with the doctors and other care providers treating her before making a decision. A similar situation occurred recently with a friend of mine. The family consulted with treating hospital staff and made the decision not to sign a DNR unless it appeared that my friend was brain dead. In that instance, my friend had a miraculous recovery and has a wonderful story to tell. He went into the hospital on Wednesday before Easter, came out of the coma on Easter Sunday - with no mental or physical damage to his body - and was discharged from the hospital with no restrictions on April Fool’s Day!
Patient No. 3: Agnes G. may be well advised to sign a DNR. She has a medical condition that would support that decision. However, she should discuss with her family, friends, clergy and/or therapist whether a DNR is in keeping with her values and her psychological well-being.
Sandra W. Reed is an attorney with Katten & Benson, an Elder Law firm, whose principal office is in Fort Worth, Texas. She lives and practices in Somervell County. If you have questions or concerns, please contact her by email at firstname.lastname@example.org or by phone at 254.797.0211.