DNR

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In 2011, in England, 81-year old Joy Tomkins got a tattoo: “Do Not Resuscitate.”

I overheard a chaplain chatting with a social worker about a patient.

“She asked me,” the chaplain said, “if a DNR order would interfere with her getting to heaven.”

The two hospice staff kept slowly moving away from me. I don’t know if the social worker responded, or what the chaplain had explained to the patient after she asked her heavenly question. Maybe my colleagues continued discussing this patient or shifted to other subjects.

I’m not sure anyone could tell the patient about heaven’s entry requirements. Different faith traditions have different views of the “better place” after death. Humans have pondered Valhalla and Nirvana and Paradise and Heaven for millennia. I’ve read and heard some Christians describe heaven as more difficult to enter than an Ivy League school. I’ve read and heard other believers claim the “pearly gates” are wide and welcoming for every soul.

Heaven’s rules may be mysterious or debatable, but what about DNR? That was the part of the patient’s question that kept nudging me. It stands for Do Not Resuscitate, and according to webmd.com, it is,

A DNR order is a physician’s written order instructing healthcare providers not to attempt cardiopulmonary resuscitation (CPR) in case of cardiac or respiratory arrest. A person with a valid DNR order will not be given CPR under these circumstances. Although the DNR order is written at the request of a person or his or her family, it must be signed by a physician to be valid.

With a DNR in place, health care professionals won’t attempt to revive patients experiencing “cardiac or respiratory arrest.” Which likely means, without that intervention, the patient will die. Many have seen CPR done by actors to actors in movies and television shows. It’s often portrayed as successful, dramatically bringing the person—the fictional character in the film!—back to life. Reality, of course, is different. In a 2009 study published in the New England Journal of Medicine, 18% of senior citizens who received CPR in a hospital survived to be discharged. That meant that 82% did not survive . . . and that’s in a hospital setting.

Furthermore, attempting CPR on the elderly and the seriously ill can result in collateral injuries. CPR can be “violent” on the ribs that protect the heart, and certainly harmful to the surrounding organs as physical force is exerted on a vulnerable part of the body. In other words, if I am one of the 18% who “survive” because my DNA order triggered a CPR effort, I may have added the complications of broken bones, serious bruising, and damaged lungs (or other organs) to my list of ailments and anguish.

But who cares about percentages? Shouldn’t all of us do everything possible to stay alive? I suspect that it’s sometimes the terminally ill patient who makes sure she doesn’t have a DNR order. After all, that would be giving up. Or the patient fears death and he wants to keep breathing, no matter the consequences. Perhaps, like the patient the chaplain mentioned, the ill person worries that DNR is against God’s will and could prevent “entry” into heaven. I’m equally confident that it’s sometimes a family member who convinces the patient that CPR must be attempted. A spouse or parent isn’t “ready” to lose a loved one. Family members might also dread death, or feel guilty about cultural or religious consequences if someone appears to “surrender.”

Hospice will honor a patient’s wishes. If a patient desires every effort made to keep them alive, those efforts will be attempted. If a patient requests a DNR order, it will be followed.

Do you want a DNR order as one of your health care decisions? Now? Later? How will you decide?

DSC_9710As with many decisions, I hope you openly talk about what you want with your loved ones. Deciding to have, or not have, DNR orders is a serious choice. And what you want when you are healthy and vibrant at 50 will likely be different than what you want at 80 after a cancer diagnosis and years of chemo and radiation. Of course you may change your mind. And then change it again. Just don’t do it privately.

In a break during a meeting, I overheard a snippet of conversation between a chaplain and a social worker. Who knows what they said before or after they walked by me?

Please don’t eavesdrop, guess, or assume with the people you love in your life. Take the time to share what you want, or to listen for what your loved one wants.

(Hospice vigorously protects a patient’s privacy. I’ll take care with how I share my experiences. Any names used are fictitious. Events are combined and/or summarized.)

Bracelet image from here; DNR tattoo on Joy Tomkins from here.

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Comments

  1. Always interesting and well written. I so enjoy your articles.
    Question: in your experience, is a DNR honored by medics who may come on the scene at home or in auto, etc. even if there is a bracelet or note in a person’s license? I have seen EMT’s go to work on patients at the scene and ignore family who say there is a DNR. Any thoughts? Karen

    • Being a first responder- unless there is a written signed DNR on the scene RMT’s are legally required to provide care unless the patient is capable of signing a refusal of care statement. Henceforth, if an individual has a DNR it is essential to keep it in an assessible central location. They are usually on a bright, often neon, color paper. Many reccommend keeping them on the refrigerator, as this is the first place EMT’s are generally trained to look for them if no one else is home or when someone else is present tell them to look if the answer is I don’t know.
      The other thing to do is have the doctor fill out multiple copies and keep them in the glove box of any vehicles commonly ridden in. I believe they have to be orginals because of the signatures that they cannot be phot copies. They are legal documents.
      If there is not a written signed DNR, they cannot legally take the word of a family member who says there is a DNR. A note is generally not acceptable, a bracelet unless a medical alert I’m guessing falls into the same, and even then unless it’s an AMA with the online/phone acess to complete information that can be verified I’m not sure. The problem with such items is DNR’s have to be signed by the individual or leagal representive and their doctor.

      • Heidi…

        Thanks for reading my reflections on DNR and sharing your perspective. You bring up excellent points.

        Long before the EMTs show, and however anyone views what CPR does or does not do to the body, I hope people talk. Talk! If someone wants to be DNR, that needs to be discussed and understood.

        And it IS hard to talk about. No one wants to contemplate death.

        I am so grateful we have first responders in my community. (And in nearly every community in the United States.) If I am in crisis, I want professionals to help me, and help me quickly! But I also want to help them. If I am at a point where I have decided to be “DNR,” then it’s up to me to make sure everyone who matters in my life knows my decision . . . and then the first responders can assist others because I won’t need their expertise with CPR or AEDs and so forth . . .

        • Larry,
          I wholeheartedly agree. The conversation needs to take place and it is a hard one. It is sad to me that given the nature of our society that EMT’s cannot accept the family’s request or statement as to what the persons wishes are.
          It’s one of those things like having a will, if it’s not written and authorized, it doesn’t exist.

    • Karen . . . thanks for reading!

      The likelihood is high that a DNR will be “ignored” by EMTs. The points Heidi makes in her comments on this post are important. Unless a DNR is easily seen and the documentation is quickly perceived as complete and accurate, all first responders will do CPR if that’s what the emergency seems to warrant. EMTs are trained to act; they don’t have time to discuss personal and legal choices with folks in crisis!

      My primary concern is that before any crisis people should talk openly about what they want, have all key people on the same “page,” and make sure the legal work is accomplished. In or out of hospice care, the lack of documentation and/or mixed messages from family members will prompt EMTs to do CPR. If everyone is in agreement about a DNR, it may be that 9-1-1 will never be called.

      Every hospice asks the family to call hospice first before calling 9-1-1. Some do, but those that don’t (for all kinds of understandable and inexplicable reasons) often set in motion more confusion and hindsight regrets.

      Hope this helps.

      • That’s the biggest key right there Larry. If there’s a DNR, is there a need for 911 to be called?
        Eventually yes, but in reality if one waits till the body temp begins to drop whether there is or is not a DNR then is irelevant.

  2. As you already quoted: “A DNR order is a physician’s written order instructing healthcare providers not to attempt cardiopulmonary resuscitation (CPR) in case of cardiac or respiratory arrest.”
    If one wants to answer the question posed from a scientific point of view. The answer is simply no. Cardiac Arrest means that your heat has stopped beating, or you have an irregular rythum causing the hear to be unable to pump blood through your body. If your heart is not beating, technically you are not alive, and if it is not pumping blood through your body in less than 5 minutes in simple terms parts of your body begin die. CPR is designed to restart your heart. The reality is CPR alone will never restart your heart. If one is able to restart a heart with CPR, then it occurred spontaneously and would have occurred with or without CPR. The only way to restart the heart with to create a new electrical impluse by shocking the it as it is a muscle using electrical impluses to contract and pump blood through the body. AED’s are used only if the heart is beating with an irregular rythem that it considered a sh0ckable rythem. In which it actually does momentarily stop the heart and allow it to reset itself. This does not mean that if you do not have a DNR in place that emergency personal will not aply an AED and in some cases they may even administer a shock if there is no shockable rythem- ex there are bystanders or family members present. We teach 1 in 20 or 5% are revived with CPR when talking about adults. Children are different because they generally go into cardiac arrest due to respitory issues/arrest thus it is a secondary issue not primary.
    What’s the purpose of CPR then?
    To circulate the blood through the body and buy some time until the heart can be shocked. CPR artifically pumps blood through the body by simulating the heat beating with each compression. With out oxegyn enriched blood cells begin to die within seconds and brain dame begins to occur after 30-4 min and is almost always irreversable after 5-6min. When the blood oxegyn level is low the vital organs” take” the ocygen first, thus damage to extremities can also occur.
    So has a DNR really done anything to change the status of your vitals? Many will argue no it does not, others will argue only sometimes because irregular rythems canbe corrected. That the opposite is true, not having a DNR, allowing CPR and an AED to be used is what changes your vitals.

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