The dad of one of my coworkers has emphysema, and it’s pretty bad. He has a “Do Not Resuscitate” order on file.
So, the other night, he was taken from the nursing home to the hospital. His breathing was labored.
The coworker showed up just as they were unloading his father from the ambulance. The doctors in the ER asked if they should put in a tube. The coworker asked his dad, the dad said yes, the coworker told the doctors the tube was okay, but no tracheostomy.
Now, the coworker is catching hell from his father’s doctor for violating the DNR.
Honestly, he had no idea a breathing tube would be considered “resuscitation.” Neither did I. In fact, in the handful of people I polled, none of them thought that would qualify. So, obviously, we are all pretty damned ignorant.
So, when you hear “resuscitation” or “do not resuscitate” what comes to mind?
I, personally, would define “resuscitation” as “do my breathing and/or move my blood through my veins if I can’t do it myself.” So, yes, a breathing tube would count, as it would be placed only if I couldn’t get oxygen to my cells through normal breathing of normal room air. Other people don’t consider it resuscitation unless the person is unconscious. Still others unless unconscious, no chest movement and/or no heart rate.
Defining your terms is important.
On the other hand, it sounds as if the patient was still conscious and approved the tube, so I’m not sure why the doctor was irked. Does it invalidate some hospice agreement or insurance payment? It could be, if he was in hospice care, that the breathing tube constitutes something other than palliative care, and now no one will pay for it.
“Resuscitation” is when they bring out the paddles & the MD (or other healthcare worker) calls out “Clear.”
A do not resuscitate (DNR) order is another kind of advance directive. A DNR is a request not to have cardiopulmonary resuscitation (CPR) if your heart stops or if you stop breathing. (Unless given other instructions, hospital staff will try to help all patients whose heart has stopped or who have stopped breathing.) You can use an advance directive form or tell your doctor that you don’t want to be resuscitated. In this case, a DNR order is put in your medical chart by your doctor. DNR orders are accepted by doctors and hospitals in all states.
Not the situation you describe. An advance directive to avoid a respirator might fit the bill. However, a patient who can talk can ALWAYS change his mind. No matter what he signed. No matter what his Next Of Kin want.
Ugh. We dealt with this over the summer when my brother had a heart attack. He was OK when I saw him after the first attack and told me for the future not to allow resuscitation, no shocking. I wrote it down and everything (I know it wasn’t binding but I needed some sense that we had had a discussion and some conclusion was reached).
Then he went into a heart failure (complete with vent, feeding tube and aortic balloon pump) and when we discussed it after he woke up he said shocking was OK as long as it was with the expectation that he had a good chance of recovering. The docs made a distinction too between resuscitation for him with the expectation of a full life and resuscitation to prolong a decline, and said the discussion would be different depending on what point he was at.
So I am really hoping he spelled all this out in the papers he signed after coming around. Thanks for the reminder; I have e-mailed him to ask about copies since I am the designated person to make these decisions. :eek:
We’re only in our late 30s. This was way too soon for all this!
Dead Body: I’m getting better!
Large Man: No you’re not, you’ll be stone dead in a moment.
Dead Collector: Well, I can’t take him like that. It’s against regulations.
I definitely agree that putting a breathing tube into a person who is breathing on his own is NOT resuscitation, by any definition that I have ever heard.
It’s impossible to comment on the OP’s situation without knowing more about how the coworker’s father’s directives were written.
However, I would (and do) strongly discourage anyone who did not want to be rescusitated from saying it was ok to be intubated. Intubation is done only when normal respirations are becoming inadequate. Bridget (and others), intubation is therefore a part of Cardiopulmonary Rescusitation.
If I were told only that a patient is DNR, I would automatically assume that intubation is not wanted. Unless it is specified clearly ahead of time that the patient is okay with intubation.
That’s my opinion anyway, coming from someone who’s had dozens of ‘end of life’ talks with patients and helped them navigate these decisions.
Sorry, let me clarify. Intubation is a necessary step in CPR if the process lasts long enough, but can be done before resuscitation is actually necessary.
I absolutely consider intubation to be resuscitation. I really like WhyNot’s definition of assisting in the work if respiration.
That said, what happened is not inappropriate. The patient or their designated representative always have the ability to revoke the directive. At least in Texas, a patient who is incapacitated to make other medical decisions can still revoke or modify an advance directive.
This is exactly the situation I faced the night before my mother died. She was experiencing a very weak heartbeat and labored breathing, caused by fluid in her lungs and other complications. It was becoming very possible that she wouldn’t pull through, but I wanted them to keep her alive at least until my brother and aunt could get here from out of town, to say good bye to her.
Her heart stopped, and some guy came out of the woodwork, waving a DNR in front of me, saying that they wouldn’t be bringing her back. I didn’t know or care what the DNR said, or what she thought she was signing. But I did know how my mother felt about the subject: She did not want to be kept alive in a vegetative state, but if there was a chance of recovery, she wanted to be given that chance. I pointed out to him that she wasn’t in a vegetative state (she was having a lucid conversation with one of the nurses only ten minutes ago). I remember arguing with that guy for at least 5 minutes, before he finally relented, and they intubated her, plus a lot of other things, and brought her back.
12 hours later, in spite of their efforts, she was failing again. The doctor asked whether I wanted “heroic measures” for her, but I didn’t want to put her through that. I told him to just keep doing what they were doing without traumatizing her, and she died peacefully a half hour later.
Now I know the first guy was just doing his job, making sure that the patient’s wishes are respected. But there really has to be a better way of knowing exactly what those wishes are, not just noticing that there’s a “DNR” in her file. My mother lived with me for the last 10 years of her life, and we discussed this issue many times (actually whenever it came up on ER). I wish, at some point prior to her death, that I had taken a good look at her medical file to be sure her wishes were more explicit.
