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Saturday, June 2nd 2012

Do We Resuccitate Too Many People?

It is distressingly easy sometimes for DNR/DNI status to be miscommunicated or lost in the urgency of a code situation. Apparently in hospitals around the world.

The National Confidential Enquiry into Patient Outcome and Death reviewed the care given to 585 acutely-ill patients who ended up having a cardiac arrest.

The watchdog concluded that cardiopulmonary resuscitation (CPR) had wrongly become the default setting.


Details of whether or not to give CPR was recorded in the notes of only 122 patients in the study of hospitals in England, Wales and Northern Ireland.

Of these, there were 52 cases where doctors had performed resuscitation on patients who had explicitly said they did not want it.

I’ve heard of cases where there is confusion during codes as to a patient’s code status. This really needs to be a conversation that physicians have with every patient that enters the hospital from eighteen to ninety-eight, whether there for a cellulitis or end stage CHF. The places I’m at it’s true the nursing staff usually has that discussion but it’s something that the admitting physician, the first one to see the patient, should bring up as well and document well.

Do not resucitate and do not intubate orders do not mean that you or your family member are not going to be treated. It does not mean that you’re taken less seriously as a patient or priority within the hospital. It merely is planning for the unthinkable. You don’t put together emergency rations and a battery powered radio and flashlights expecting a natural disaster but instead in case.

A DNR order means that in the event of cardiac arrest or events leading to such no measures will be taken to resuscitate the heart including cardioversion by shocking or chest compressions or drugs to help make the heart beat. A DNI order means that no tube will be placed into the trachea to allow for mechanical ventilation in case the patient stops breathing on his own. The decisions are usually made together as DNR/DNI orders.

A DNR/DNI decision can be a sensitive topic of discussion and a difficult decision, not only for patients themselves but, sometimes even more so, for families when patients cannot make the choice for themselves. There are several things to consider when seriously pondering a DNR/DNI decision. First and foremost is the patient’s pre-hospitalization condition, independence and quality of life. This is probably more important than the patient’s actual prognosis from whatever condition the patient is being treated in the hospital for. The fact is that, independent of what disease your battling in the hospital, if you go into fullblown, true cardiopulmonary arrest you are very unlikely to do very well. Patients who get ACLS – chest compressions, shocks and drugs to restart their heart – and intubated for arrests do very, very poorly. In this study just 11% of patient’s who coded survived to hospital discharge. Some patients who survive are left with devastating new deficits, including potentially brain damage or long term care requirements such as tube feedings or ventilation.

Second, patients and family should consider the financial cost of cardiopulmonary arrest. As morbid as this sounds, ACLS leaves patients who are already unlikely to survive their hospitalizations, with significant ICU stays and undoubtedly significantly increase the cost of the patient’s last days of life. Patients who survive these codes to hospital discharge may require longterm care outside the hospital with significant financial burden to their families. I know this can see a tactless consideration but if we’re honest with ourselves it should be an important one when deciding DNR/DNI status.

Third, patients and families should consider the quality of death they desire. While providing for the best chance of survival following a cardiopulmonary arrest a code, and the care that follows, can be a brutal and undignified process. It is true there is likely no pain associated with a code but chest compressions will leave patients with broken ribs and long term time on the ventilator and other procedures in the intensive care setting can be upsetting to family and friends.

A DNR/DNI decision is a very personal decision. Ideally it is something that should be discussed with family and their physician before a patient requires hospitalization. At the least however both the admitting nurse and physician should have early conversations with all patients to clarify their wishes if the patient was to suffer an arrest.