* * Anonymous Doc

Sunday, December 12, 2010

We need a national initiative to educate people as far as what it means to choose between full code and DNR status (do not resuscitate).

The truth is, it's a messed up question. No one wants to tell a doctor to let their loved one die. And very few doctors are even asking the question until we're at a point when we think the patient should be DNR no matter what the family says.

But somehow-- and I assume it's through the popular culture and what we see on TV and in the movies-- it has percolated through the patient population that there are gradients of care, and that it's meaningful to say things like:

"No heroic measures"


"She wouldn't want to live like a vegetable"


"Do CPR, but no paddles, no breathing tubes"


"Paddles are fine, but that's it"

These are not answers. And unless someone has watched a code happen, I don't know how we can expect them to know these are not answers. It's not a continuum. It's yes or no. Maybe we wish it wasn't, but in practice it is.

We're not intubating someone because we want to. We're intubating because we have to clear the airway. We don't know if CPR is going to work. We don't know how much function will be lost. Once we start, we're going for it. There's no point where you can reasonably stop and say, hey, the scale has tipped, at this moment we've found the spot on the gradient that matches the family's wishes, and we should stop.

It doesn't work like that.

I think there's a fear that no code means no care, and being DNR means you're signing an order to die. I think patients don't realize that when your heart stops, that's really bad news. People in good health, who are doing well, don't normally have their heart stop. They just don't. DNR status doesn't come into play when someone comes into the hospital with the flu, or a broken leg. DNR status comes into play when someone is dying, regardless of what we do.

So on the one hand, I feel like patients underestimate what it means to have a code event. But on the other hand, I feel like they overestimate what we're likely to accomplish in the event of a code. Much of the time, the patient is going to die anyway. And in most cases when they don't, they will not come back to the same level of function they had before. Nursing home care, loss of brain function, all that fun stuff that people don't actually want to happen, but are quite likely to.

And, yeah, it's probably better to regret coding someone instead of regretting not coding-- but the point shouldn't be to minimize possible regret. The point should be to figure out the patient's wishes and what they want to happen.

This is not a rant against full code. I absolutely want to be full code. Hopefully for a long, long, long time. I'm healthy, my odds are probably as good as they can be in these kinds of situations. But if I'm frail and demented, have virtually no quality of life anyway, no hope to recover to any sort of quality state, then I don't want to be coded.

And the silly part is that we go through pains to ask patients or their families what they want, we try to talk them through the options, we try to make them understand what they're choosing between... and then we do what we think we should do anyway.

I don't mean to be flippant about that. I haven't seen anyone truly subvert a family's wishes-- if you insist full code, if you are clear and definitive about it, you're getting the full code, I have no reason to think anyone is going to fight that. But if you think you're somewhere on the continuum, and you've given us some wishy-washy answer about no vegetable, yes paddles, no breathing tube, like it's a menu of lifesaving options you're choosing from, and your father is 103 and doesn't know who he is, then the attending is probably going to do a slow code, and basically just go through the motions.

But the real solution should be education. And I don't know how to make that happen. There are so many things so many patients need to be educated about-- nutrition, preventive screenings, when to go to a hospital and when not to, etc-- but this is a reasonably important one.


  1. I could be wrong, but wasn't the idea of educating people about end-of-life issues (like DNRs) originally part of the health-care reform package? That is, until our friend Ms. Palin made here ridiculous comments about "death panels" and got everyone in a tizzy? So now, instead of people facing the facts, everyone continues to try and navigate this mess with their heads firmly planted in the sand and their tail feathers exposed for all too see.

  2. Thanks for this piece. I am responsible for a very old relative who has signed DNR papers and this helps me better understand all that. I am still not completely sure, however, what to do in the event of a serious accident at home or a prolonged period of discomfort. If you can shed some light on these areas, it would be a great help to me and I am sure many others. I try to imagine what I would want done if I were her, but this does not always provide compete answers to all possible scenarios.

  3. If your relative is having what appears to be a medical issue you should still take her to the Emergency Room or The Doctor. Being a DNR does not mean she won't be cared for by all means possible. Let's say she had a perforated ulcer that was causing her stomach pain, then the Doctors would probably still do an operation on her to fix it (after factoring in her other comorbidities and assessing whether she is a good surgical candidate). The only difference is that if her heart were to stop (so she's dead), nobody would do CPR/Shock her with paddles/Give lots of drugs to try and restart it and bring her back. In all honesty if her condition(s) proceed to the point her heart stops - it's probably going to be better that way. Many times in this situation if someone codes, and then they're successfully resuscitated the end up in the ICU with all sorts of tubes coming out of them before their heart ultimately stops again.