Tuesday, October 10, 2006

DNR, Who decides????
From today's New York Times: The Last Word on the Last Breath:
The patient, only 35, had been in a persistent vegetative state for 15 years. Recently, he had developed septic bedsores and pneumonia. His kidneys were failing, and despite the feeding tube, he was losing weight. Now he was in cardiac arrest. He was dying.

But the young staff doctor had no choice. The patient's relatives, convinced that the man could communicate, had insisted that all revival efforts be made. So the doctor gave the patient a few mouth-to-mouth breaths, climbed on the bed and began vigorous chest compressions, trying cardiopulmonary resuscitation.

The patient was intubated, shocked with electric paddles and injected with epinephrine. Blood spurted as a central line was inserted into the large vein in his groin to administer medicine and fluids. EKG electrodes were placed on his arms and legs: streams of paper spilled over the floor, as the hospital room filled with people and shouted orders.

After 15 minutes, the doctors called the time of death.

"Kneeling on that bed, doing CPR, felt not only pointless, but like I was administering final blows to someone who had already had a hard enough life," said the doctor, Daniel Sulmasy, now a New York internist, medical ethicist and Franciscan friar, recalling this experience from his internship. "Why was I forced to crack this person's ribs? Why couldn't we have let the patient die in peace?"

It comes down to medical futility versus the "desire to do everything":
Many doctors believe that their medical judgment about whether CPR will be effective in a given patient's case, and their knowledge of the havoc it can wreak on a dying body, should prevail. But a patient's representative, who is often a relative, may believe that every medical option should be exercised and that a miracle could be just a chest compression away. And patients' families, spurred on by TV medical dramas, often mistakenly believe that CPR is almost always effective - a notion emphatically disproved by studies.
The article cites a 1996 New England Journal of Medicine article about the unreality surrounding codes on TV. Here it is, Cardiopulmonary Resuscitation on Television - Miracles and Misinformation:
Background Responsible, shared decision making on the part of physicians and patients about the potential use of cardiopulmonary resuscitation (CPR) requires patients who are educated about the procedure's risks and benefits. Television is an important source of information about CPR for patients. We analyzed how three popular television programs depict CPR.

Methods We watched all the episodes of the television programs ER and Chicago Hope during the 1994-1995 viewing season and 50 consecutive episodes of Rescue 911 broadcast over a three-month period in 1995. We identified all occurrences of CPR in each episode and recorded the causes of cardiac arrest, the identifiable demographic characteristics of the patients, the underlying illnesses, and the outcomes.

Results There were 60 occurrences of CPR in the 97 television episodes - 31 on ER, 11 on Chicago Hope, and 18 on Rescue 911. In the majority of cases, cardiac arrest was caused by trauma; only 28 percent were due to primary cardiac causes. Sixty-five percent of the cardiac arrests occurred in children, teenagers, or young adults. Seventy-five percent of the patients survived the immediate arrest, and 67 percent appeared to have survived to hospital discharge.

Conclusions The survival rates in our study are significantly higher than the most optimistic survival rates in the medical literature, and the portrayal of CPR on television may lead the viewing public to have an unrealistic impression of CPR and its chances for success. Physicians discussing the use of CPR with patients and families should be aware of the images of CPR depicted on television and the misperceptions these images may foster.

How did these shows paint a misleading picture? Let us count the ways:
First, these three television programs give a misleading impression about the kind of people most commonly given CPR. On television, children, teenagers, and young adults accounted for 65 percent of the patients given CPR. Of the total number of deaths on the programs, 83 percent were of nonelderly patients. In fact, cardiac arrest is much more common in the elderly than in children or young adults.

Second, cardiac arrest on television was often due to acute injury, the result of gunshot wounds, motor vehicle accidents, or near-drowning; only 28 percent of the patients had primary cardiac arrests. In real life, 75 to 95 percent of arrests result from underlying cardiac disease.

Third, CPR succeeded more frequently on television than in the real world as reflected in the medical literature. On all three shows combined, 75 percent of the patients were alive immediately after their cardiac arrests, and 67 percent appeared to survive in the long term. On Rescue 911, which focuses on the successes of emergency services, the survival rate after CPR was 100 percent. Of the patients on ER, 65 percent survived the initial arrest; three of these patients died before discharge from the hospital. On Chicago Hope, 64 percent of the patients given CPR initially survived cardiac arrest, and 36 percent survived to discharge.
The reality:
Rates of long-term survival after cardiac arrest as reported in the medical literature vary from 2 percent to 30 percent for arrests outside a hospital, and from 6.5 percent to 15 percent for arrests that take place inside a hospital. For average elderly patients, the rate of long-term survival after cardiac arrest outside a hospital is probably no better than 5 percent. For arrests due to trauma, the reported survival rates vary from 0 to 30 percent. Clearly, the rates on television are significantly higher than even the most favorable data reported in the literature.
The role of physicians and family members varies by state:
New York is one of the few states with a law that directly addresses resuscitation orders. In New York, even when a doctor believes that CPR would be medically futile, if the patient is incapable of indicating a preference for or against it and the patient's designated representative insists it be performed, the physician must ultimately go to court to prevail. Texas, which has a complex advance directive law that includes checks and balances, ultimately sides with physicians, immunizing them from litigation.

Hawaii passed legislation this year giving great weight to a patient's "comfort care" document, which specifies the patient's preferences in dire medical situations. Nonetheless, if the patient has indicated no resuscitation but the provider's own conscience dictates otherwise, a medical professional may override the document.
The article touches on the history of codes:
In New York, doctors at one hospital had a casual way of indicating to staff, without informing families, which patients should not be resuscitated : purple stickers were affixed to their charts. Occasionally, stickers were placed on the wrong charts or fell off. After these and other stories came to light, New York passed a law in 1987 that addressed the conditions under which a physician could write a D.N.R. order. Patient consent was essential.

The statute did say that if resuscitation was "medically futile" and no representative could be found to consent to the D.N.R. order, a doctor could write one, if another doctor also signed it. Under these narrow circumstances, a doctor's judgment that CPR would be useless was sufficient. But what if a "medically futile" patient's decision-maker insisted that CPR be performed anyway? Could a doctor's judgment prevail?

In 2003, an upstate New York hospital, seeking policy guidance, put the question to Attorney General Eliot Spitzer. Mr. Spitzer interpreted the state law to mean that even in these cases, a doctor could not enter a D.N.R. order over the objections of a family. A doctor's only recourse was to proceed to mediation, and then, if necessary, to court.

"We have gone from one extreme to the other," said Dr. Kenneth Prager, chief of medical ethics at New York-Presbyterian/Columbia, "from physicians making unilateral decisions to the situation where the family and the patient have all control."
Inability of communication and the inabliity of families to accept the futility of the situation leads to half-assed exercises such as these:
At the same time the New York statute was being enacted, stories around the country emerged of doctors going through the motions of a code for the benefit of a family. Hospital slang like "slow code"(to suggest a leisurely walk to the bedside), "Hollywood code" (in deference to TV hospital programs) or "light blue code" (an allusion to code blue, the term for a cardiac arrest resuscitation) became public.
Dr. Nic describes the origins of CPR:
In 1960 JAMA published an article titled "Closed-Chest Cardiac Massage." It was based on 5 (yes 5) case reports about acute cardiopulmonary arrest. It concluded that cardiac massage was proven to be effective. This was the birth of CPR. In 1993 the Journal of the American Board of Family Practice did a 30 year review of in-hospital CPR. Of the 19,955 patients in the study 15% survived.
And also decribes more code buffonery:
From a treatment perspective, it is the last one DNI but not DNR that poses a severe problem. We can do every part of the resuscitation process except put in a breathing tube. In order to perform CPR/recuscitate a person the first step is securing the airway, i.e. intubation. No amount of chest compressions to move the blood through the body will do any good if the blood has no oxygen to carry. Even if a person is young enough to get a blood pressure and pulse back, their brain has been deprived of oxygen.

In my mind this is doing a patient harm. I in good conscience could not fill out the paperwork to make a patient DNI but not DNR. And to be honest, I view my colleagues who do so with much less respect as physicians.
I wholeheartedly agree. IMHO DNI but "full code", "shock only", "chemical code" orders are in a word, b.s. And as far as that goes:

The "B" and "C" do little good for the patient without the "A". When we engage in "Hollywood codes", "slow codes", or "light blue codes" we are treating the families, not the patient. When we know better.

See Kevin's take on this here
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