Whether you believe in science, God, neither or some combination of the two — we can all agree that death is inevitable. Due to the finality of our lives, each of us should understand and prepare for that moment not only for ourselves but also for our loved ones. As medicine continues to advance and people live longer, we have a generation of baby boomers who are now entering their 60s and 70s. It is important to know their wishes now when they have the full capacity to make these decisions. If family or health care providers have no knowledge of how you want the end of life to take place the situation can become complicated.
I am sure you’ve heard of the infamous DNR: “Do Not Resuscitate.” The DNR conversation is something that doctors, patients and families alike can dread, but can go smoothly if the right questions are asked before the end of life is near. DNR is a written legal order that withholds cardiopulmonary resuscitation (CPR) for a patient in the event their heart stops. As I wrote that last sentence, I found myself disliking the word “resuscitate”. Using the word can be misleading. When CPR is performed, the chances of survival are slim. Most studies show dismal rates of patients walking out of the hospital after undergoing CPR. So to say, “Do Not Resuscitate” implies that when we do CPR we can miraculously resuscitate patients and therein the confusion lies. Before initiating CPR patients and families should be aware of how it is performed and who benefits. Physicians should explain that we will do everything in our power to save their lives if a reversible cause is apparent. But we should also make clear that if a situation or illness arises in which a patient would not benefit from extreme measures, then we will make sure the patient is comfortable during their foreseen death.
Imagine this scenario: an elderly family member with many chronic medical problems winds up in the hospital and is actively dying. The patient is in such critical condition that they are unable to communicate. You, as their next of kin, must make medical decisions now. You are probably in tears and unable to comprehend the most basic of conversations. While trying to keep up hope and praying for your family, a doctor you have never met comes in to speak to you about your sick loved one. He asks you about “code status” and whether the patient is DNR. You ask him what he means. “If the patient’s heart were to stop beating do you want us to try and resuscitate him?” In your current emotional state you yell back at him, “Of course I want you to resuscitate him, do everything you can!”
The patient goes into cardiac arrest (heart stops). A code is called overhead, and the team rushes to the room. CPR is initiated. Someone begins pounding on the patient’s chest trying to make the heart pump again. Ribs are cracking. Another person is sticking needles into the patient to obtain an intravenous line while someone else is drawing blood from another limb. Anesthesia comes into place a tube in the patient’s mouth. 10, 15, 20 minutes have gone by. The family is outside of the room in shock. The patient continues to be pulseless, and the code is stopped. The patient has now passed.
To be clear, if you made the above decision you are not in the wrong. The majority of people, under those circumstances, would want everything done. If you never had DNR discussions with a health care provider, you would not have been able to make a fully informed decision. It’s imperative that in those types of life or death moments a doctor explains to you what is going on, what the chances of survival are, and what the quality of life would be for the patient going forward. It’s your job as the decision maker to trust that the physician understands the risks and benefits of these interventions and whether or not they would do more harm than good. In several countries across Europe and Asia, the DNR order is not even discussed with family as health care providers are able to determine who would benefit from CPR based on medical judgment alone. In the United States a patient has the right to make this decision, and if they are unable to then their health care proxy makes that decision; if no health care proxy has been designated, then the next of kin decides. The above scenario could have potentially been prevented if the code status had been talked about at an earlier time in life.
Every patient is extensively considered and treated. What many family members sometimes fail to realize is that DNR does not mean, “Do not treat.” If your physician is asking you about your code status, it does not mean he has given up. He still wants to treat you but is looking at your age, condition and quality of life when deciding what treatment would suit you best. There are many times that CPR works under the right circumstances. I have chosen to dedicate my career to the field of pulmonary/critical care because I believe that there are patients who are critically ill and can improve with CPR and mechanical ventilation. But the scenario of causing patients more harm than good while they are actively dying happens in hospitals every single day across the country and can be corrected with education.
End-of-life is not an easy topic to discuss when a patient is healthy and certainly not an easy topic to discuss in the hospital while a patient is sick. Have a plan to discuss your options with your family and health care provider. It will make your life and your loved ones much more dignified in the end.
Hassan Patail is an internal medicine resident who blogs at The Daily Dose of the Doctors Patail. He can be reached on Twitter @hspatail.
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