DO NOT RESUSCITATE & DO NOT INTUBATE (DNR/DNI)

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“We have a 92-year-old male in cardiac arrest. The nursing home reports that he is baseline nonverbal but seemed off the past couple of days. When they checked on him during morning rounds he was found unresponsive. He is currently full code. His initial rhythm was V-Tach. He was shocked once with no return of spontaneous circulation. He received 3 rounds of epinephrine, was intubated and currently has chest compressions in progress. We’ve been working him for 30 minutes and he still has no pulse. We should be at your facility in 8 minutes. Full history available on arrival.” 

 

Unfortunately, the patient would be pronounced dead shortly after arrival. We did everything we could to revive him. The paramedics shocked him to try to get his heart back into a rhythm that is sustainable with life. They performed high quality CPR (chest compressions) and provided medications to try to bring this man back from the dead. We would soon find out that this was a non-verbal patient with multiple medical problems. With the list of medical problems that he had, his chances of surviving such an insult as a cardiac arrest was slim to none to begin with at 92. This brings me to discuss a point that we often ask as doctors, but rarely properly explain. What does Do Not Resuscitate / Do No Intubate (DNR/DNI) really mean?

 

People often tell us, ‘Do everything doctor.’ Unfortunately, in so doing, we often ‘torture’ patients in their last minutes or days of their life. Proper CPR will break the front portion of most of the ribs in someone’s chest. The first time I heard and felt the crack of someone’s ribs from my hands while doing CPR as a medical student, I became queasy.  When we shock someone, we use 200J (Joules) of electricity, which can cause skin burns to the chest. We also inject the patient with medications to try to revive a dying heart.

 

In an overwhelming majority of cases that survive the initial insult, they go on to have tragic permanent neurologic deficits or other major organ insults, which results in unnecessary suffering. A large majority of the unhealthy, chronically ill, older patients will never come off of a ventilator and will require long term care secondary to brain injury sustained during the cardiac arrest. The remainder of their lives will be spent with significant deficits or require 24-hour nursing care.

 

Being on the receiving end of multiple patients in cardiac or respiratory arrest, I feel that we are experts in the subject on what it is like to ‘do everything.’ Unfortunately, the reality is that your chances of survival are not good in an overwhelming majority of the cases (there are always exceptions). There are a lot of misconceptions about this topic and I feel a lot of patients make poorly informed decisions when it comes to what they want done for themselves or their loved ones.

 

When people talk about CODE status (i.e. do you want to have CPR done, intubation and cardioversion) we often present it as ‘if your heart stops.’ A better and more accurate way to ask this question would be, ‘if you die, do you want us to push on your chest, shock you and put a breathing tube into your lungs so we can connect you to a ventilator in an attempt to keep you alive?’

 

The exact rates of who survives are tough to find, but the studies that are available are not encouraging. The statistics are typically broken down in to IN HOSPITAL and OUT OF HOSPITAL cardiac arrest (so those who die in hospital vs those who die out of hospital). To put this in perspective, we will review a few studies. If you die outside of the hospital, one study from Japan found that you have a 2% chance of surviving to hospital discharge with a good neurological outcome. Out of people registered in the CARES registry (a database of 70,000 US patients), about 8% survived to discharge from the hospital after suffering a cardiac arrest. Another Canadian study found that about 11% of patients who had a cardiac arrest survived to discharge from hospital. This number increases in the IN HOSPITAL CARDIAC ARREST GROUP to about 18-20% depending on what study you review. The important part about these statistics are not the numbers though, it’s the type of patient that actually survives and this is where the general public is not being properly informed.

 

There is a large MISCONCEPTION on surviving cardiac arrest and it’s believed to be directly related to television (thank you Hollywood). In the mid-90s Duke University did a study which involved watching 97 episodes of “Chicago Hope”, “ER”, and “Rescue 911”.  Do you know what they found about patients who had CPR during the show? 75% of these actors survived the cardiac arrest with almost 70% being discharged from hospital with no neurological deficits. They were totally fine. This is an extremely different number than the reality of 2-11%.

 

The reality of the situation is that most of the patients who survive are actually younger and healthier patients. The majority of patients that we attempt these heroic measures on are actually unhealthy older patient who likely have almost no chance of survival and very little chance of “good” survival. Patients who have terminal illnesses or are chronically ill fall into this low chance of survival. Any delays to initiation of CPR in these cases (delay of only 5-10 minutes) reveal that there is almost no benefit of these measures. Although these statistics sound dismal, I think it’s important to have this information to make an INFORMED decision. 

 

I think it’s also important to mention that just because someone is DO NOT RESCUSITATE and DO NOT INTUBATE (DNR/DNI) it DOES NOT mean do not treat. We will still provide aggressive medical care up to the point that someone requires resuscitation. We will help supplement breathing, provide fluids, give antibiotics, and other medications to treat your illness. The only thing we would withhold are the heroic measures, which have been proven of limited benefit depending on circumstance.

 

Please feel free to post in the comments section or provide personal anecdotes as you wish. If this is your first time reading one of our posts feel free to follow us on Facebook or our blog (www.reviewmyresults.com) as we attempt to post monthly. We try to do a topic in emergency medicine or medicine in general that is informative or interesting to the general public. Please check out the blog for past topics we have covered. All for now…

 

Dr. Paul