Posts Tagged dnr

OLD does not mean: Ok to Let Die

Journals customarily publish letters to the editor responding to recent scientific articles, and much less often (if ever) do they allow comments on their humanities pieces.  Yet on par with other types of academic work, a good narrative can educate, stimulate discussion and spark controversy.  

In a recent Annals of Emergency Medicine, Dr. Leana Wen’s Change of Shift titled “Old” is a great humanities piece, honest and powerful.   However, the case as described is deeply concerning, compelling me to respond. 

A demented DNR/DNI patient presents to the ED in respiratory failure and is allowed to expire after a resident physician confirms the advanced directive and withholds non-invasive respiratory support on the request of the health care proxy.

The story is a true-to-life documentary of a thoughtful and caring clinician’s deference to advanced directives and family’s wishes. Readers might even celebrate this example of “death with dignity” in the
ED with family present and patient’s spirituality respected. 

I would agree, if not for the issue of autonomy. 

“Help… me… breathe…” the patient begs the resident upon arrival.  At that moment, it seemed clear that the patient chose to receive non-invasive ventilatory support until further clarification. Did his age, DNI status and reported dementia invalidate his apparently lucid demand?

The resident discontinues the BIPAP upon the request of an “adamant” niece.  A dialogue between the resident, her ED attending and the niece about efficacy, comfort, non-invasiveness and reversibility of
BIPAP was left entirely out of the narrative, hopefully to save print space and not because it did not occur. 

I must applaud this physician’s efforts to understand the patient’s life, medical history and spirituality; however I wish the patient’s most up-to-date directives were not ignored. 

A narrative such as this does more than tell a story; it implicitly teaches clinical norms and limits. I am concerned that the next generation of doctors will learn to simply allow a DNI paper and a health care proxy to overrule a human being pleading for a breath. 

To me, a situation this complex warrants a presentation of more complex decision-making process than the one described in “Old.” 

Some may say this is too much to ask of a narrative.  I would respond that narrative have a power to change hearts and minds; a power that comes with a responsibility to the reader.

Boris D. Veysman, M.D.
University of Medicine and Dentistry of New Jersey
Robert Wood Johnson Medical School, New Brunswick, NJ

Reference — Wen, L.S.  Change of Shift: Old.  Ann Emerg Med. 2011;58:305-306.

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The Electronic DNR: Epic Fail

A screenshot from Google Health.

A screenshot from Google Health.

I applaud Google for trying to bring medicine into the 21st century with things like Google Health and Google Scholar; somebody’s gotta try. But their latest addition shows how even a huge organization full of hugely intelligent people can get something wrong in health care, because our world is simply a different beast.

Last week Google announced that it was making it easier to complete, upload, and store your own Advance Directive on Google Health. They even worked with an advance directive organization to have free advance directive forms for all the 50 states. (Warning #1 right there: things are different in all 50 states.)

They then go on to talk about how easy it is to “share your Google Health profile with your doctor, your family, or anyone you like.” And voila, epic fail.

Great, I say, that a patient can share his or her own medical information with loved ones or one’s doctor (more on electronic medical records and personal health records in another post). But these advance directives are not available in a searchable database by, say, name or date of birth. I’d argue that as Emergency Physicians, there are few people who need to know a patient’s code status more; perhaps intensivists, but the vast majority of patients going to an ICU setting who are going to need intubation are already intubated when arrive in the unit, and they’re going to stay that way. It’s a vast minority that get intubated in the ICU.

Our critically ill patients are usually so critically ill they’re not able to be speak, or they’re altered, or too somnolent to be thinking correctly, let alone be able to type and remember their login to Google Health. Or they’re technically DNR/DNI, but they have a family member that says do everything, and another that says “no, don’t,” and no one has any paperwork for anything. Or their DNR form isn’t valid, or they’re from another state, or their health care proxy isn’t available.

Or, say in a perfect world, you get a computer nerd online dweeb (say, me in 60 years) who has everything online and shareable with the world at large. Is the physician going to spend their precious time trying to login to a website to find out if the patient is DNR/DNI if they don’t know already, or is she going to try to review my medications, medical conditions, run through my differential diagnosis, assess my airway, and get oxygen, suction, and intubation supplies ready at the bedside?

We just recently had a case of a woman who was DNR/DNI for many years who was found in respiratory distress by the home health aide at 2am but who didn’t know the patient was DNR/DNI and couldn’t find any of the paperwork. So EMS intubated her. It was a frustrating situation for all of us–EMS, the ED staff, the patient’s family–but what was EMS to do? A perfect illustration of best-made plans falling through when things get stressful. (Luckily she was in flash pulmonary edema, and after a nitro drip we were able to extubate her in the ED.)

Look, I’m just about as techie and computer-friendly and live-your-life-online as anyone out there, but a lot of this stuff isn’t well thought-out, isn’t safe, and has no guarantees. So, Google–and emergency medicine and health care as a whole–we’ve got some work to do if we’re ever going to figure out the advance directive (and even more to take it online):

  • Make a central clearinghouse. Is it going to be Google Health, or the US Living Will Registry, or some government entity? Who knows, but the only people who you really need to know about your code status are your family members and health care providers who may want to code you or intubate you. I’m not going to spend precious minutes searching through multiple websites (or possibly any) to figure out where you’ve stored your online code status.
  • Confirm the patient’s identity. So all I need to know is your Google password, and I can upload a DNR form and forge your signature? (Because really, if you’re altered and septic, I’m not going to be able to verify your signature.) Scary.
  • Guarantee that the online forms that are uploaded are legally binding or accurate. I don’t know how we do this, but we usually want an original copy to initiate an DNR/DNI order, not a copy–and certainly not an uploaded duplicate.
  • Somehow confirm that the DNR order is the most recent. Sure, it’s great to have the information available online, but what if the copy is 3 years out of date and the patient changed their mind 2 years ago and is now full code, yet the only information we have available says “DNR?” That certainly seems suboptimal as well.
  • Decide if we should even have advance directives. Some argue that they’re a waste of time and energy, when they real time should be spent letting your loved ones (and especially your health care proxy) know your wishes. If we’re not legally protected to follow advance directives (a dead patient isn’t going to sue us, but a grieving relative sure can), it’s sure difficult not to listen to that relative telling you to “do everything.”

I’m all about end-of-life care and palliative care and actually believe we don’t do enough of it in the emergency department (but how can we?), but I’m still not sold on the advance directive if it has little-to-no legal weight behind it, and I’m even less impressed by Google’s online attempt.

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