End-of-life decisions can be complex, even when patients have a DNR
End-of-life decisions can be complex, even when patients have a DNR
Make sure you, patient, and family are clear on goals of resuscitation
The widespread publicity surrounding the case of Terri Schiavo may have brought end-of-life issues to the forefront for the general public, but ED managers deal with these challenges on a daily basis. The proper way to treat these extremely ill patients in the ED — whether or not they have a do-not-resuscitate (DNR) order — is, like the Schiavo case, hardly cut and dried.
"When I was an intern, I had a Jehovah’s Witness patient who had a wallet card saying, Never give me blood,’" recalls Gregory Luke Larkin, MD, MSPH, MS, FACEP, professor of surgery, emergency medicine, and public health at University of Texas Southwestern Medical Center, and director of academic development and medical director at the Violence Intervention and Prevention Center of Parkland Memorial Hospital, both in Dallas. "When we got into the elevator alone, he grabbed me and said, Doc, give me the blood.’"
DNRs can help supplement information that occurs in a verbal conversation, but often they’re not the be-all and end-all, he emphasizes. "Sometimes you have to be careful and have a conversation with just the patient," Larkin advises.
Tammie E. Quest, MD, assistant professor in the Department of Emergency Medicine at Emory University in Atlanta, says that even when a patient has a DNR order, you may not know it at first. "In many states, patients have arm bracelets or specific identifiers, but my general sense is that they are grossly underused by patients," Quest says.
Depending on the urgency of the case, the ED’s approach may be to treat first and ask questions later, Larkin says. "The initial impulse to save a life is considered by most commentators to be the right impulse," he says. "For example, if I have someone who is losing blood pressure and their heart is fibrillating, I’m not even going to get a history until I get some electricity and shock the heart. That’s the very nature of emergency medicine."
Quest recognizes that ED physicians and nurses have a hard time withholding treatment, and that most times they end up resuscitating. "But part of the art of [being an ED physician] is to guide families," she adds. You can tell them you really do not think certain treatment would be effective and that you do not recommend it in this case, Quest says. "Yes, we can intubate first, but this can mean a delay in the execution of the wishes of the patient and family as well as the potential inappropriate ED and hospital resource utilization dedicated to ventilated patients."
Quest says in all cases where life-threatening situations are present or likely — whether the patient has a DNR or not — the prime question should be this: What is the goal of care? "When I think about patients coming in with DNR orders, I ask myself, is resuscitation useful? What is the goal for the patient?" she says.
No surgeon would open up a patient if the surgeon felt there would be no benefit, she notes. "With issues of resuscitation, it’s a lot more delicate — a life-and-death moment," she concedes. "But this is one of the courageous moments for a physician to talk with the patient and help them understand if treatment would be futile. When we think it is likely not to be beneficial therapy, we need to say so."
Larkin agrees. "We are under no obligation to provide physiologically futile care," he says. "If the family disagrees, you should sit down with them and talk, put them at ease, and let them know we are here to do all we can for them — but mostly for the patient."
This is not such a difficult conversation to have, Larkin says. "You say, I know you love Mom, and you want her to live forever, but what would she want?’" he says. "Talk about the person, and don’t pull any punches."
On the other hand, if a patient has been intubated but there is a valid DNR or power of attorney, and removing the tube seems logical, then that is clearly the way to go, Larkin says. "If she’s trying to die, who am I to interrupt that process?" he says. For example, a patient may have metastatic cancer to the brain and is going to the hospice next week but stopped breathing that day. "We are fairly reasonable people," Larkin says. "We’ll let the lady die in peace if it’s consistent with what she wanted."
Quest says there are really two types of patients for whom DNRs are appropriate: Those who have one on their charts, and those who do not have one but who should consider it.
"For example, if you have a patient who is at high risk for cardiopulmonary arrest or distress, I would advise you to discuss with the patient or their surrogate what their wishes would be," she says.
Other situations where a "potential DNR" exists would include patients who have noncurable diseases — very advanced-stage cancer or HIV, for example. "In those cases, it’s helpful to stimulate a discussion," says Quest. "If the patient does not have a DNR but is lucid, I use this as an opportunity to discuss it in front of the family."
She recalls a case several weeks ago where a man in his 90s was admitted with a very slow heart rate. "This was life-threatening arrhythmia," says Quest. "I told him there was a good likelihood this could be fixed, but in the event his heart stopped beating, would he want me to use artificial means to restart it? He said he felt he had lived a full life and would not want his heart restarted." Quest subsequently discussed this with the man’s daughter, who confessed she never knew that he felt that way. "I charted it as the patient having expressed this wish, even though it might not be legally binding," she reports.
In addition, says Quest, you have to decide what the endpoint of resuscitation is. "The patient is never going to be healthier than he or she was just before this last illness," she notes. "If you are out running and have a cardiac arrest, it’s likely you could potentially live a meaningful life, but if you’re lying in bed in a nursing home and you have dementia, all we can do is make you as good’ as you were when you came in."
This information should be shared with the family, she notes. "If I think a patient could be a candidate for resuscitation, I like to have this conversation earlier rather than later," she advises. "Tell the family, I think Grandma’s heart could stop; if we start it, she will not be any better than she was yesterday. Tell me what Grandma would want.’ If you don’t do that, you don’t even give her surrogates the opportunity to know what will hit them."
Finally, says Larkin, the ED manager must model these behaviors for their staff. "You must show empathy for the patients," he says. "But you must also keep underscoring that sometimes we may withdraw or not provide certain treatment, but we will never, never withdraw care. You never stop caring for the patient."
Sources
For more information on do-not-resuscitate orders in the ED, contact:
- Tammie E. Quest, MD, Assistant Professor, Department of Emergency Medicine, Emory University, Atlanta. Phone: (404) 616-3594. E-mail: [email protected].
- Gregory Luke Larkin, MD, MSPH, MS, FACEP, Professor of Surgery, Emergency Medicine, and Public Health, University of Texas Southwestern Medical Center; Director of Academic Development, Medical Director, Violence Intervention and Prevention Center, Parkland Memorial Hospital, both of Dallas. Phone: (214) 648-2904. E-mail: [email protected].
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