One suggestion.
Do not call 911
54
Will a first responder called into your home honor a POLST? It seems like with time of the essence, they wouldn't read a document. When my mom was dying of leukemia, she had a DNR and wore a DNR bracelet so anyone who came in contact with her would know her wishes (and hopefully comply). Is there something similar with POLST?
13
I do not want to have to die TWICE, after being resuscitated the first time. And I don't want to live to be 90-something and have great difficulty remaining independent and taking care of myself if at all.
I'll be 75 soon. I am adamant about not wanting to be resuscitated. If I'm gone, I want to keep going elsewhere, whatever that portends. So I wear both a necklace and a bracelet with DNR / POLST medallions.
Yet when I was in the ER a year ago, nobody noticed either, and local EMTs have told me they do not abide by them because they're afraid of getting sued by families.
37
In my 60s, I'm now conflicted about this and most every medical intervention the stats tell us is unlikely to have a positive outcome in the elderly. We are all human beings and humans routinely beat the odds at all sorts of things, medical issues included. We do get lucky sometimes!
I don't see how anyone, highly trained and experienced doctors included, could ever know with complete certainty they should not attempt any intervention on an elderly patient unless that individual had made their specific wishes known.
I know I would want my chance at a good bonus year or two, but hate the idea of falling in with the majority and lingering in a coma or otherwise a burden on my daughter.
10
Over 30 years ago when I was training to be a volunteer EMT I met plenty of paramedics who admitted they just went through the motions on their elderly patients...and that was strictly for the benefit of the family member watching, since the paramedics knew there was no realistic chance of resuscitating grandma.
20
I have been a paramedic for over 20 years. I have performed CPR on numerous patients and have also withheld CPR for those with valid DNR orders. The difficulty that arises all too often in the "field" occurs when we arrive at a patient's side and are told a DNR exists however is not readily available. If the document is not presented on our arrival we have no choice but to begin treatment immediately. Thus, I encourage caregivers to make sure that DNR, POLST or similar documents that direct emergent patient care always be at hand so that unwanted treatment is not initiated.
34
As an ER physician for 25 years I saw only one patient survive and actually leave the hospital after an out of hospital cardiac arrest. Unfortunately he left after a post-arrest stroke. I never want CPR. It’s a very expensive myth on which a huge industry is based. Fire departments and EMS depend on it.
25
My perspective as an ER physician for thirty-five years:
We have gotten better at resuscitation, especially in younger patients. But I have to tell you, the times when I have felt multiple ribs break in a patient I know will not likely survive (older and unwitnessed), makes me feel lie a torturer. Period. That's tough when you know the individual is dying in pain which we have inflicted.
There is much understanding in this string of comments about POLST. POLST is a very common sense and lets the patient makes choices as to what he/she desires.
I dare the naysayers to do their homework.
113
As we become more overpopulated in this country, the funds for medical care will be diminished. Many of us are still alive only because of modern medicine and new drugs. I would rather not have an unsuccessful CPR procedure that left me addled or brain dead for the next few years, creating a burden on family and society. We are not meant to live forever. Our culture (or religion) has created an unreasonable fear of death.
38
Very interesting glad to read this...I moved from my home of forty years in NYC to my elderly parents home, where my brother was the caretaker of my Mom at 88yrs old and suffering from myelodysplasia and dad who was 91 yrs old and ….after two yrs, I found my Mother unresponsive and weak as we tried to get her into the car , to take her to Emer.I believe my Mom died
given the dark pupils, this in about five minutes we then called the rescue squad they asked does she have a DNR...well there began the mystery of unpredictable outcomes ...and I say I simply never thought about it..eventually the CPR was used on the ground and I did not know about the crushing of chest.why just of course I want everything done to bring my Mom back or is she dead anyway..on to the next emergency the brother was found by me accidentally in the room with his 97 yr old Dad by me, stopping by, finding 69 yr old brother noncognitive,naked,with 97 yrold Dad with Dementia sitting next to him,I immidiatly took him to emergency, to find 9 brain absesses, on MRI, next day after hopeless operation asked to take off life support.So I had no documentation at all,no POA by now no good anyway,,no DRR well I can only say, ..its very unethical to seemingly take ones life away at an instant..so I managed to keep brother alive 4 more days.
2
I have a DNR. Hardly a day passes without a story that hospitals, religion-affiliated nursing homes,
EMTs, and others do not, or will not, honor it. This is an awful reality for many, if not most, of us. Whose life is it anyway?
20
Getting older here myself. The article must have been good. I was uncomfortable reading it. Maybe I'll forget it. God blesses us with dementia. Our families not so much.
6
Great article highlighting a problem that we have unfortunately known about for a number of years but which has become
overshadowed by the unbridled enthusiasm for often unselective CPR. My late colleague, Dr. Lawrence Scheniderman, and I pointed this out in our discussion of the ethics of "CPR for all" in an article we published almost three years ago (available at https://doi.org/10.1080/15265161.2016.1265163) entitled "Irrational Exuberance: Cardiopulmonary Resuscitation as Fetish". I am glad that this topic may finally be getting the attention it deserves.
Philip M. Rosoff, MD, MA
Professor Emeritus of Pediatrics and Medicine
Duke University School of Medicine and Medical Center
24
We had to argue with the medical staff about resuscitation and keep vigilant to prevent it when my father was dying. He had a DNR in place. He asked for nutrition to be withdrawn in his final days and comfort measures be used. Many of the staff put their religious beliefs and desire to not have a death on their hospital statistics over his comfort and desire. They put him in an ambulance and sent him home where he died two hours later. What discomfort did that trip home cause him? But, the staff got their wish and his death wasn't on the record of deaths in that hospital.
27
My 95-year old mother has a MOLST, and it gives her and us, great comfort. She is ready to go, even though she is in fairly good health in body and mind. But she doesn't want to be lying in the hospital with tubes coming and going. She has made her peace and wants to go when it's time.
11
CPR works so seldomly, that this is practically a non-story.
4
Having been through the journey of aging with many in my work life and having now buried both of my parents, I am glad we have a very, very different practice in Canada.
After a certain age, as part of the intake process for accommodation, treatment or care, there is "the conversation". That is a frank discussion of your wishes should you be found unconscious, collapse or become incapacitated.
My father was, when admitted to first a hospital and then a convalescent care home, bluntly offered the choice of a "full response" including CPR, administration of drugs and other medical interventions and a fast trip to the hospital to keep him alive or, as was said, "Do nothing except care and comfort measures.". His choice, as is the choice of many others, was "Do nothing except care and comfort.".
As his POA I knew his wishes and would respect them. The doctors and hospitals did, as well. That choice was not offered in palliative care but was made for him (after all, that's what palliative care is).
While I respect the choice of those who do wish proactive measures to be kept alive, I am thankful that "the conversation" was a part of the admission process for my father and gave the family all the information we needed to support my father's own decision.
"The conversation" should happen well before it is necessary. I have made sure my own POA and my family knows my own thoughts on the matter.
14
As a clinical chaplain in an acute care hospital I witness the moral distress of my fellow clinicians who are compelled to sustain resuscitation efforts on our aging patients when all know the outcome is dire. The cracking of ribs, the violent pounding, all seem antithetical to dignity and respect at the time of death.
It is interesting to see some of the comments of other readers who seem fearful of the opportunity for shared decision-making around end-of-life preferences. In my work on a palliative care team I see the POLST document as a written testament to a conversation between providers and individuals (or their proxies) regarding what dignity and respect mean to them at end of life. It documents, in a portable medical order, how medical care will align with personally defined values and goals.
51
This challenge extends to younger patients who are terminally ill. My 63 year old dad, suffering from the last stages of cancer, was rushed to the emergency room when he lost consciousness. The EMTs revived him in the ambulance despite the futility of this effort . My mom and I had to take on all the doctors to allow him to die quickly, rather than suffer for weeks. What is the point? To extend his pain? To run up health care costs? To improve the hospitals statistics?
42
It must be hard for people who are trained to intervene, to do nothing. The urge to do something, to try, even if you know it's likely futile, must be strong. This is something that needs to be addressed in medical training, so that practitioners have thought through the emotions beforehand.
19
DNR ("Do Not Resuscitate") should be replaced with DNAR ("Do Not Attempt Resuscitation") precisely for the reasons listed in the article. For a high percentage of people with advanced illnesses, these attempts are ultimately unsuccessful and only interfere with the natural dying process.
12
It's a pity that the people who know the least about POLST are the most vehement about spreading false information. To reiterate - POLST is to document YOUR wishes and no, doctors are not legally allowed to just overturn them.
13
It is reported by researchers that 4% of the people in death row are innocent, and that is often cited as a good enough reason to end the death penalty. Here, you report that 2 % of the people over 80 who get CPR will survive to leave the hospital.
Death penalty cases also cost a tremendous amount in legal fees, procedures, transportation, emotional turmoil. Another reason often cited as why the death penalty should end. In contrast, the longer the CPR-treated patient survives, the more procedures will be needed, and costs will explode.
Since the young doctors (mostly alpha males, under 60) want to be so rational and fiscally-responsible, it seems that what society needs is to decide how much we are worth. The electronic data is slowly getting our medical records together, and soon it will be possible to decide when a person has reached their social limit, at which time their medical services can and will be terminated.
Alternatively, we can look at how many remarkable recoveries there are and celebrate them. We can use and celebrate the medical procedures we have to do everything possible to save everyone, even the old and wrinkled and sickly, complaining and hard-to-medically-manage old bats, because that's what those damned procedures are for. The quality of that life can then be judged by the person in it, and they deserve a chance to decide that---even if they have lived long enough only to ask to be allowed to die.
2
Our son is an attorney with a department of health in another state. One of their cases involved a man who went into cardiac arrest while in the ICU with his wife and daughter, The attending nurse noted that there was no DNR but she also said to herself: “I know this family. There is no way that they want their last memory of this man to be seeing us break his ribs.” The man died, and the family agreed that the outcome was appropriate.
The hospital reported the nurse because, you see, she failed to do the “right” thing, which was to have CPR performed. She was allowed to surrender her license. It is unclear to me whether the reaction of the family was a factor in her not being prosecuted.
I repeat that story in an effort to persuade others of the importance of a health care directive.
21
@Susan Guilford
Presuming the wife was her husband’s surrogate, did the nurse obtain her consent to not attempt CPR? If so, I don’t understand how she would be in trouble. Surrogates have the same right as patients to refuse treatments, including CPR.
7
I was a medic for 15 years in the states, and I respected DNR (do not resuscitate) orders of all sorts, written or verbal.
When it's time to die, it's time to die, and we should respect the patients' wishes.
22
The comments from Chelsea re. MOST in NC - or POLST anywhere - are incorrect. I am a physician in Texas who uses MOST and advocates for wider of use of it throughout the state for the reasons cited in this article. POLST documents (actual local names vary by state, e.g., MOST, MOLST, IPOST, LaPOST, etc.), and just as important, the conversations that lead to their completion, fill a gaping hole in the healthcare delivery system. Whereas out of hospital DNR orders are binary (CPR, yes or no) the POLST document creates an actionable medical order set that specifies exactly what the patient wants. It asks the binary CPR question but goes beyond it to the “what happens next” question if they want CPR, e.g., whether or not to be placed on CPAP, given fluids, blood pressure support, tube feeding, etc. Because it’s an actual medical order, the first responders (usually paramedics) can act on it and NOT start aggressive measures if the patient did not want them. A key pint: POLST documents are intended for people who have serious progressive illness, people for whom it would not be a surprise if they were to die in the next year or two. Others may want to complete but it those who understand the process would not usually recommend it. Chelsea may have had a bad experience or an ax to grind, but what she is saying about MOST (POLST) in NC, or anywhere, is factually incorrect.
40
I'm more a victim in the opposite way, though I may soon become victim in the way described as well.
At 70, I was incredibly healthy, trekking in the Himalayas with a couple of young friends from Nepal, lifting weights, doing tai chi, kayaking, what fun, what fun.
After 5 years of pressure from the system, I tried a statin drug for six months, and that was the end. Photos at StatinStories.com give some idea what happened.
I'm not alone. The US has no compulsory system for tracking the adverse effects of drugs. There's insufficient proof of benefit with statins for primary prevention. People over 75 seem not to benefit at all, yet about half are on statins.
So...to the point. Now I have a frightening disease. Autonomic neuropathy: blood pressure sky high, then suddenly dropping by half to very low; freezing cold in 85 degree room, then bursting into full-body sweats and drenched in 60 degree temperature. Daily muscle cramps from feet, to forearms, calves, Right foot suddenly completely numb, hip collapses. Torn tendons and ligaments. Intermittent gasping for breath in bed.
The disease progresses. It's been 8 years now, no treatment. No suggestions as to where to go for potential treatment. And many friends, both local and nationwide, in the same sinking boat.
To the point: I can't seem to get any doctor to really talk with me about how this ends. Will I be dragged through hell as the article describes? Will I have a say in it? I love life, and I don't want to..you kn
9
@sing75
The data on the benefit of statins for both primary and secondary prevention are actually pretty darn impressive. Drugs have side effects and risks. If the benefit is not worth it to you, that's fine. But that doesn't make the population wide benefit any less. Plenty of people have side effects to vaccinations but that doesn't mean vaccines benefit us on a population level.
7
@AK It appears this is a side effect that doesn't go away when the meds are discontinued. That's the difference.
9
@AK Rather than simply denying the accuracy of what you say, let me provide some facts.
The Nov 2016 issue of JAMA contains an article entitled "Lots of Studies, But the Data Are Weak," which states that there is no proof of benefit for statins for primary prevention. I believe that it's the only article in that issue that has no disclaimers regarding ties to the pharmaceutical industry.
My doctor told me that statins for primary prevention may prevent one case of cardiovascular disease in 60 people who take it for five full years. That's a pitiful performance, even if the drug were totally safe. Meantime, numerous articles in journals such as the BMJ find adverse effects in about 15% of cases.
But we don't know the full story on adverse effects because we have no compulsory system for reporting them. Doctors aren't required to report, and when they do, the drug-maker hounds them with further paperwork--all lost and unpaid work time. (This told to me by one of my doctors.)
People over 75 have never even been studied, but half the elderly are put on statins anyway.
The majority of the expert panel of 2013 who set statin guidelines had ties to the pharmaceutical industry. True.
Remember HRT, Celebrex and Vioxx (one of these caused about 80,000 premature deaths), Thalidomide, etc? Medications are a profit-making business. Statins are cheap, but their sales volume is huge.
Lastly, two of the local people I know who've lost the ability to walk are MDs.
14
The DNR for my elderly, bedridden, demented aunt was prominently displayed and reinforced in conversations with aides, doctors, and social workers.
When she was dying, her aide called me, not 911; when my aunt stopped breathing, the aide called the police, who arrived before I did.
My aunt was dead in her own home. Sounds right to me.
74
Thank you , Dr. Span, for pointing out that health care professionals to a great degree believe that doing CPR after cardiac arrest is the "right"
action to take, regardless of the aftereffects.
It isn't that paramedics and Drs. should know the individual patient's situation and preferences if they have been recorded, it's that frontline professionals might need to step back, and examine how their own assumptions or values influence their actions.
For EMTS in ambulance service, it sounds as if changes in guidance are needed to make what happens when the ambulance arrives congruent with the patients wishes and advance directives. It sounds as if it remains a kind of no man's land where minutes of care might save a person, but might condemn someone with a chronic terminal condition to unnecessary pain.
Families DO sometimes push for interventions, both ordinary ( like CPR) and extraordinary( tubes and machines to sustain life) when the patient in question may have preferred to be allowed to go - especially when the interventions reduce the quality of life.
But families are also highly influenced by what a Dr. or nurse says - or neglects to say - to them. or by the raised eyebrow, or turning away, or other body language. So -- back to getting health care pros to envision the negative results of applying CPR when what might best be done is to alleviate the patient's pain and anxiety.
6
What you want depends on what you have. If you have close family, and have taken care of your papers, then you can go comfortably.
But if you live alone and kick the bucket, who will feed the dog? That's an agonizing death.
7
I’m confused. Doing CPR on a person in hospice care? No, no, no.
11
@Chief TB
This was in-home hospice,and a family member called 911 - -and EMTs started CPR. Sounds as if the family hadn't really gone through a complete decision-making process ahead of time.
12
@cheryl
I am surprised, when my mom went under in home hospice they explained to family and we explained to home care workers what her wishes were. No measures to keep her alive. Agreed to before entering hospice program and instructions on counter in home.
12
When the family of a demented 99 year old nursing home patient with bedsores tells me to do everything after the patient has a massive heart attack I say we already did everything. If we let the family make demands at that point, why are we not pushing for a heart transplant for her as well? I think if the families were expected to pay for the extra months of ICU care that sometime results from excessive futile resuscitation, they would not be so sanguine about it.
30
How about we devise some method of CPR that does NOT involve breaking all your ribs? (No, I don't know what that would be, but I'm not a genius inventor.)
4
Personally I’ll take the 1 in 50 chance. If it doesn’t work it doesn’t work. Then they can pull the plug.
5
@Daniel Even if your quality of life before the event was limited to dementia and/or chroic pain?
27
@Daniel You have the right to document that choice with the expectation it will be honored. So do those who choose not to be resuscitated. EMTs and ERs often override Polsts and start treatment because it’s their default setting, and they don’t know or don’t think to ask what the patient wants. It is agonizing for families.
20
I am not a doctor, but have worked where passengers could die. We always try to save their lives, even if they are 100 year old. That commented, I know that in Scandina e g they don't really make great effort to, whilst in Italy they do.
2
My very elderly father had DNR signs on the fridge near the back door, one at the front entrance and one on the mirror in his bedroom. He was 94. He told his children and his doctors his end-of-life wishes and was exceedingly clear - no nursing home, no extreme measures.
Every person is different. What’s important is to tell those close to you what you want. Write it down, too. That way, agonizing decisions can be avoided. My father was not a believer in “life at all cost.” I am so grateful that he was so clear with me.
129
I remember a patient in his 80s who was golfing with his wife and another couple when he experienced chest pain. Shortly after they got back to the pro shop, he collapsed in cardiac arrest. A police officer who was dispatched with EMS for the complaint of chest pain witnessed the arrest and started CPR immediately. On our arrival the patient was in the “shockable rhythm” mentioned in the article. We worked at resuscitating him for over an hour, exhausting the medications we carried in our vehicle, before he was successfully resuscitated in the emergency department. Before we left the ED after completing our paperwork, the patient was awake and trying to get his breathing tube out. Three weeks later he was back out on the links.
This was 33 years ago, and I remember it like it was yesterday. The reason I remember it so well is that, between my time as an EMT/paramedic and emergency department RN, involved in probably hundreds of resuscitation attempts for patients in cardiac arrest (more than I really care to even think about), this is one of the fewer than five patients who have walked out of the hospital, under their own power, neurologically intact, and able to resume their previous lives. And of those patients who survived and went back to their prior existence, he was the only one older than 50.
‘Nuff said.
228
@David Great observations! But the problem is that we humans tend to focus on the miraculous five (or one over 50) and (willingly) overlook the hundreds of failures.
40
@David
My FIL had a bypass at 80 and another one at 95 and lived happily to 100. I'm afraid today they would just let him die. Do not sign a MOLSt document.
22
@Chelsea - You can't speak for anyone else. Many older people are ready to go and do NOT want the pain and trauma of extraordinary measures because in most cases there's never any return to any quality of life. In fact, many people at those ages already don't experience a good quality of life. And no, today they wouldn't just have let your f.i.l. die. They'd be very likely to resuscitate him even against his previously expressed wishes.
44
Why, if you've already gone through the hard part - the fear and bodily fighting as you feel the world start to slip away - why make you go through this again? If you have a terminal illness (advanced congestive heart failure, advanced cancer, or dementia/alzhemiers) the next thing on your medical records should be a do not resuscitate order. DNR even with drugs. Yes, your family will cry, and you might miss great-grandson's wedding, but all of you will also miss pain and suffering that far surpass the joy of having you around a little longer.
14
@Kathleen The question becomes--What is "terminal"?
In two hundred years after we take the religious folk stories out as a baloney fable on the the idea of an afterlife , an AI program will make death by euthanasia as a government proxy quite desirable ,we will accept this notice that time is up and make room for other living people in a crowded planet to survive.
11
@Carlyle T. You go first.
6
@Frances Grimble
I said this is a probability forward in 200 years .
Sorry to disappoint you :-)
3
CPR on elderly patients can shatter the sternum and ribs, often leaving the patient in worse condition than before this heavy-handed (pardon the pun) resusitation technique was applied.
14
Worse than dead?
2
@Daniel yes
16
@Jean claude the damned If that's the way it turns out after treatment, then there is a truly easy remedy.
1
Absent advanced directives that can be presented to Firefighters, EMTs and Paramedics, out-of-hospital Advanced Cardiac Life Support for cardiac arrest is identical to in-hospital cardiac arrest.
Ways to reduce futile resuscitation:
Families and patients can be counseled in advance on how NOT to have this forced against their wishes, absent advance directives. Example: A geriatric patient has made it clear to family that they do not want aggressive resuscitation if they are found unresponsive and in cardiac arrest in the privacy of their domicile. A delayed 911 call, allowing for physical signs of prolonged cardiac arrest to develop, will allow the advanced life support (paramedic) responders to respect the family wishes and not initiate resuscitation.
In other situations, resuscitation, when performed with sensitivity to the shocked and distraught family, can be the start of the acceptance that their loved one has died. They come away with, “everything that could have been done, was done”. Paramedic protocols are the same as a physician led ER or in-hospital resuscitation. Absent this effort, until our bias towards intervention and with poor knowledge of outcomes, this may not be the setting to explain futility and a ‘no point in starting’ change in practice. Laypersons have had years of exaggerated positive outcomes from movies and television, and expect resuscitation. With an experienced crew, this can be nuanced to fulfill both needs; interventional but respectful.
5
There are some people, even elderly people, who are in such denial about their own deaths that they flatly refuse to contemplate it or discuss it.
Other people are able to consider their own future death with objectivity and calmness. However even some of these people have trouble trying to imagine or visualize the health care situations they might encounter and the decisions they would want made on their behalf. Repeated conversations about what makes life worth living to them personally, and when it would no longer be worth living sometimes allow an interviewer to help the person approach the choices on the advance directive document.
The decisions are easier for family to make if the person is extremely old, has dementia, or is near the end of a terminal illness. It is harder for families if the person was functioning at an acceptable level and then had a sudden crisis like a stroke or heart attack. You suddenly have to deal with a new reality and it make take a few days to even know what has happened.
7
My mother had a DNR filled out by a very competent attorney, all of her decisions made, exactly what she wanted. When she went into the hospital with severe congestive heart failure, the doctor on staff asked me if I was an only child. I said no I have an older brother who is disabled. He informed me that he would not honor the DNR because my brother was not present. I informed him I had power-of-attorney and had legal right to present the DNR. My mother did not want to be intubated as she had multiple serious issues beyond the congestive heart failure and COPD. My husband had to go pick up my brother to bring him to the hospital so the doctor could discuss the situation with him, as well. While we were waiting the doctor was able to use a C-Pap machine and she survived. She was never the same and knew no one. She ‘forgot’ she was a heavy smoker and passed a few months later. I feel guilty in not being able to fulfill the promise that I made to make her last days peaceful. Even though she had taken care of her will and advance directive in advance of needing it, it meant nothing because the doctor choose not to honor it. It’s been 12 years and it still makes me feel bad.
46
I’ve never heard of any legal requirement for the input of a second family member and I’ve signed numerous DNR orders in multiple states.
I suspect that this particular physician had a bad experience in the past when a second relative showed up afterward and made a fuss, questioning the validity of the first relative’s request, paperwork not withstanding.
It happens.
14
Thank you for raising another important topic. I realize I need to seriously consider what paperwork I, and my husband, need to have completed to avoid this unwanted treatment.
12
I haven't read the literature in a while but discussing the issue I always wondered how much validity there is to a declaration of cardiac arrest without electroencephalographic determination. Pulse determination seems to me highly subject to error. In the CPR classes I have attended we were always told there really isn't much hope unless you can shock the heart within 7 minutes with an AED etc,
You’re right that people, including healthcare providers, are unreliable at feeling a manual pulse in a patient in cardiac arrest. It’s a stressful situation and generally why we have better ways to determine if someone has spontaneous cardiac activity/circulation.
No healthcare team will treat a cardiac arrest without an ecg. Even an AED used by laypeople is simply using a computer to automatically interpret ecg rhythms.
Virtually every cardiac arrest treatment algorithm uses an ecg tracing to guide decisions.
3
When it comes to discussing code status or de-escalating care, I find that most people are uncomfortable with "removing care" or "doing nothing." I do my best to explain to patient's and their families that it is not about removing care or "doing nothing", but about providing care and dignity through a focus on comfort as a person is dying. That is certainly not nothing.
While I am only a resident with several years of experience, my most vivid moments have been the times I have been able to help people die with dignity and comfort -- whether an elderly man with a failing body but strong mind, a young father with advanced lymphoma, an elderly woman with cardiogenic shock and no meaningful recovery, or an elderly man who was repeatedly sent to the MICU for aspiration and all he wanted was to eat ice cream.
25
I’m an ER doc who has resuscitated many “hopeless” cases. When I have discussions with family about what the patient’s wishes would be or what is best for the patient, I find that even when the patient has made his/her wishes clear, the family needs more time to come to a full understanding of what is happening. The family most often asks that “everything be done” which, at best, buys the family some time to come to grips with the situation and say their goodbyes.
10
Great information for people that do not work in healthcare.
It is ok for a physician in a hospital to tell a family, "we have done all that we"can instead of "do you want us to do everything". The everything is CPR which as the article states is cruel punshishment for someone in there 80s and 90s.
21
One cause of cardiac arrest in younger people is total blockage of a major coronary artery. If shocked on time, and emergency angioplasty is performed, the person may have a good outcome.
However, younger people with end stage cancer, for example, are poor candidates for CPR, though sometimes it is requested at the last minute, As a former nurse, I saw this happen several times, and the family members of the sick person can be hysterical, reverse the No Code order in a panic mode. It unfortunately doesn't work to save the patient. One night had admitted a dying woman, who was in hospice at home. She coded on the night shift, and she had a premonition she was going to die that night, which is why she got admitted, as she wanted to be coded. Of course it failed, the nurse who took care of her had a horrible experience and the rest of the night staff didn't want to talk about it, aside from saying this admission and code should never have happened.
I do recall an expression for frail, very elderly nursing home patients who code - a slow code. A full code done on such a vulnerable, really old and compromised person is almost an affront to their dignity. Be realistic when establishing code status.
21
As a physician, I saw my own father, a surgeon, die in a cold emergency room among unfamiliar faces with alarms blaring. My dog, on the other hand, died peacefully in my own living room, in his favorite place next to my sofa. This is a timely article. Unfortunately, politics and "death panel" discussions set as back.
55
This is something I am quite familiar with.
In 2012, my 97 year old father who was experiencing organ failure and GI bleeding arrested while his home health person was with him. She called 911, then me. He didn’t have DNR posted and the EMT told me he had no choice but to start CPR. Dad passed within minutes.
I worked my entire career in hospitals. I have witnessed at least 5 cardiac arrests of staff or visitors within the hospital. Maybe one or two were resuscitated.
Yesterday during my “yearly Medicare well visit” my physician asked me, if I arrested in the office, did I want to be resuscitated. I had to think about this, which kind of upset her...no one lives forever and it is a quick way to go.
16
When my MIL moved to a senior residence this year, they required that she execute a POLST. We discussed it with her doctor while she was filling out the physician’s assessment form, and I learned for the first time how extremely unlikely it is that someone her age (well past 90) could ever have a meaningful recovery from cardiac arrest, and what terrible trauma CPR would likely cause in the almost certainly futile process. In the end she opted for no CPR, no feeding tube, and only comfort- focused medical treatment.
82
We should be helping people transition to death with dignity. We treat our pets better than we treat our parents.
35
Totally agree. I think veterinarians are the most “humane” of practitioners. And I’m a human doctor.
27
@Deirdre I vividly remember one sad day when we had to have our 17-year-old dog euthanized. She had lived a long life as a "rescue" dog with us, but had multiple illnesses and had stopped eating. As the vet was preparing to administer the injection, he said, "I hope when I am old and sick, someone will love me enough to do this to me". I tear up just thinking about it. He was so right.
23
@Deirdre In some states - including my own - this is possible. It's call assisted suicide - voted in by statewide referendum several years ago. And the religious fanatics are constantly trying to reverse it.
5
Am an ICU physician and try very much to NOT resuscitate such patients. It's absolutely inappropriate. But, "doctors" are not the exact culprit here. Autonomy reigns supreme in American medicine and that's another debate. But, if a patient says he desires it, we have to do it. Now, we can call it after a futile point, etc, but it's still a brutal way to go. Listen, we can talk families out of it -- but that's not going to happen in a hospital so easily -- we are busy treating other patients and if they desire aggressive care, it's frankly a "Well, I told them no and they still desire it, why not?" situation. Alas, if docs keep a patient on inappropriate support for their last couple days, one also stands to make TONS more in billing. I use lines like "CPR is not going to change anything that other than your loved is going to pass having cracked ribs and won't be able to say goodbye to you" and it can work occasionally but if someone is against it (a CPR) then we have to listen to it! My hospital system has even banned the term "Do Not Resuscitate" -- we fear it makes a family member feel they are keeping care from their patient. We use "Allow for Natural Death" -- which is really whats going on. Lastly, patients in hospitals and who have been getting care are truly being "resuscitated" throughout. If their heart stops amidst it -- some chest compressions and epinephrine is not going to change much.
37
I really like your suggestion. Allow a natural death.
14
@Cool Dude
That's a good way to phrase what is happening, not "nothing," but allowing a "natural death." Where is this place of sanity?
9
I have end of life discussions several times a day as an Internist. Most people say they don’t want to be maintained in a vegetative state. I find myself saying several times a day: “everyone says the same thing, and yet that so often doesn’t happen”. After CPR in the elderly, “success” means ending up in the ICU with tubes coming out of veins, arteries, lungs, urethras. And then, bed sores, incontinence, restraints, recurrent sepsis. This is why DNR orders need to be clear and part of regular “physicals” and well visits. Make it easier for your family by spelling out what you don’t want. These decisions are made by families now, not doctors. Give your loved ones the permission to say it’s ok to die. A quick death is what everyone wants, yet it so rarely happens. Let it go. Death happens. It doesn’t need to be violent.
47
@AKM
So clearly put. I should print this out and carry it with me, give to my doctor and family.
Please, dear lord no, no violent -- or noisy -- or overly highly lit -- endings.
Peace and quiet, please.
20
Although highlighting a very serious issue, the article really does not address the main reason practitioners initiate CPR on what are essentially gasping skeletons: the overarching fear of being sued by the patient's family. As a practicing physician, I can attest to the fact that medical-legal concerns are one of the prime motivators of physician decisions. Even if the immediate family might not sue, there is always the worry that some relative living far away, who previously had little interest in the patient's condition, might decide to try to make some money by suing the physician. It's far easier to initiate CPR and then let the chips fall where they may. Unless the patient (or his/her family) presents the doctor with a gold-engraved Do Not Resuscitate document, CPR will be performed. Indeed, this issue is yet another example of the profound dysfunction of the American so-called healthcare system.
23
Truly: "I think we’ve entered this zone where we’re trying to escape ordinary death.”
And we should know better.
But ...
4
Thank you, New York Times, for sharing this article. As a physician, I feel that CPR is commonly misunderstood by the public. It is glorified in medical TV dramas, but the reality of it is quite stark.
If you think about it, CPR is only done on dead people (no pulse, no respirations). Your body had to have been pretty sick to have died in the first place. Considering that, it makes sense why CPR is so often unsuccessful. Even when it brings back a pulse, the person often has to be on life support and is brain dead or has suffered similarly devastating neurologic consequences. CPR does the exact opposite of allowing you a peaceful, natural death. These are the things I wish the public knew about CPR.
Even more traumatizing is the effect of CPR on the family. They have to watch as their loved one is stripped naked, their ribs are broken by chest compressions, lines and tubes are stuck everywhere, and tons of healthcare providers are streaming in and out of the room. If the person makes it to get back a pulse but then requires maximal life support indefinitely (essentially being a vegetable), it often falls on the family to decide when enough is enough. And that is often the harder decision - after all, who is ever ready to say goodbye to a loved one?
Please don't let yourself or your loved ones get put in this situation. Discuss with your family, and then document your wishes in advance directives like POLST. Know what you are choosing.
151
It is sad that in 2019 we are just beginning to ask “should we start?” rather than “should we stop?”. For so many years the American public has been sold a bill of goods about CPR and how effective it is when the statistics show otherwise.
Subjecting a frail elderly body to CPR rarely has a good outcome and is a brutal indignity. When will we accept that our time on this earth is finite, and that nothing can prevent us from dying? Let us go peacefully without strangers assaulting us.
25
While I fully agree with most of what you wrote I have to say that calling CPR “assault by strangers” belittles the role of the first responders, nurses and doctors that work diligently to treat all patients with dignity and compassion in their final moments. We are not “assaulting” anyone. We are providing what is currently the only intervention available to us to treat cardiac arrest in any victim regardless of age. I have done CPR on the elderly and it is awful and rarely effective but never is it “assault”.
5
@Terri - legally if CPR is not wanted, it is considered assault and battery.
3
@JoAnne Only if the provider knows or should have known otherwise. Implied consent applies to unconscious patients and children unless specific and validatable directions to the contrary are presented in a timely fashion. You never have to establish that someone wants life saving treatment, but if you can quickly validate that they don't then you honor that.
Legally anything we do is battery unless the patient consents. Being unconscious is one way to consent.
Us first responders are trained on the legal aspects, you know.
3
I'm a volunteer EMT and have performed CPR lots of times. Most of the time for *anyone*, it fails (out-of-hospital post-arrest survival rates are less than 10%, and most of those have brain damage). We do it because we're not positioned to decide this for the patient, excepting a few extremely specific cases - traumatic (e.g. severe car crash) arrest, lividity or rigor mortis, or "conditions incompatible with life" (decapitation etc). "Really old and dead in a hospital bed in the first floor living room" is a real bad sign but it's not good enough - would you want us to make this judgement call for your family? If something results of this and our protocols change I'd of course follow them, but it makes me nervous to decide such things without so much as a heart monitor - paramedics, who do have monitors and training to use them, can consult with a physician to obtain pronouncements in the field already.
This is the patient's (or their proxy's) decision. There's forms we're trained to honor, such as the Polst form mentioned, and DNRs. But if it's not obviously located (on top of a bedside table, please!) and valid, we don't have the time to waste looking for one even if we're pretty sure a patient would have benefited from having one.
But if grandpa's died in his sleep, just don't call 911! An emergency number gets an emergency response. Probably EMS will just leave him there after getting a pronouncement, and you'll call the funeral home or coroner just the same anyway.
20
@Robert - One of the things I've learned is that if you call 911, you ARE going to get an emergency response. If the patient has a DNR, it's better not to call 911 at all, although I understand the tendency to panic and want to call for someone else to deal with a frightening situation.
12
People are owners of their bodies and it is up to them to decide about DNR. I am a physician in late 80ties and I do not want to be resuscitated with the risk of being an organism without functioning cortex. We do have in each state a (sort of) solution through advanced directives, either MOLSt or POLST (orders for life sustaining treatment) but no one walks around with a copy on his/her chest.
I have a pendant with DNR sign but I doubt that a well meaning eager-bever will read or even understand it. There should be a standard pendant and its image on every resuscitation kit. We probably need a big lawsuit winning money to take care of a person resuscitated against own wishes.
20
Seems to me the "relative" should never have called 911. The woman was 90 and had a terminal disease.
14
I just realized that I’m 79 , oh Dear !
13
My question is: why didn’t this hospice patient have a DNR order? She absolutely should have, and if she did, no one would have started CPR ....
Absent a DNR order, the default _has_ to be CPR .... first responders don’t have the luxury of combing through a persons medical record to determine the person’s age, medical comorbidities, etc before deciding whether it is appropriate to initiate life- saving treatment.
From the perspective of first responders, it’s either full code or DNR, and the next steps can be worked out later.
11
I was a volunteer EMT for several years. On no fewer than three occasions I was required to perform CPR on very sick, elderly patients whose families called 911 when they didn't know what else to do.
It is a horrible thing to do to an elderly patient who, in the unlikely event they survive, will never, ever recover from the broken ribs and damage caused by compressions. It's cruel for the patient and traumatic for the personnel required to perform it.
My elderly mother is in assisted living. Her chart is flagged "Do Not Resuscitate," as will mine be.
24
Always, Always,Always, make your wishes known when you go to a hospital! If you want a DNR, Insist that your doctor right the order in your chart and ask to see it. Ask for a sign placed in plain view so that everyone knows your desire. Wear a medic alert necklace, not a bracelet. No one is going to look at your wrist when they are under pressure. Having been involved in the tragic results of successful resuscitations that end with severe disability (brain dead is dead), I can say that it is heartbreaking to witness. Both the family and the staff are traumatized.
15
In 2018, I was 44 and at the hospital for an outpatient procedure. I unexpectedly had a cardiac arrest. I had a shockable rhythm and was revived about an hour later. I gained consciousness during the resuscitation process and could see and hear (very intermittently), and feel the shocks each time the defibrillator was used. Given my age, I understand why and I'm thankful for the team who didn't hesitate to save my life. I walked out of the hospital and able to return to work. However, if this were to happen again, I would want a DNR. Even though my cognitive abilities were intact, life after a SCA can be very different. I might have returned to a normal life, but the one thing my SCA taught me was not to be afraid of death. Dying this way is one of the best ways to go and guess what, you're going to die one day. After this experience, I'm able to talk about death with my family and the length of measures I would want to save my life again. In a few years, that outlook will change and I'll again communicate my wishes through an updated advance directive. There is no way I would want to relive this experience again. Sometimes, you have to realize it's okay to die.
43
What an amazing experience to share. Thank you.
15
My mother died from an aortic aneurysm. She had been given treatment options but refused due to her advanced age and the complicated, possibly unsuccessful recovery that surgery would require. Her team of doctors respected her wishes, as did her family. When her time came the aneurysm did not rupture suddenly as expected, but leaked, slowly killing her over several hours. She was in great pain but refused to go to the hospital for relief because she knew exactly what they would do to her.
Do to her. Not for her. Our terminally ill deserve better.
29
Both of my parents had DNR's (Do Not Resuscitate) orders in place before their natural deaths. Make sure to give one copy to the doctor, one to the nursing home if they are living there, and all family members. Respect the person's wishes!
Get you health care priorities in order long before you need them.
14
For some confusing reason, Do Not Resuscitate is separate of Do Not Intubate. That needs to stop.
There needs to be a massive education about what happens when elderly people are coded by EMT's, nurses, doctors. The public has no clue and they aren't ready. Even the elderly who don't want herculean efforts spent on them don't acknowledge that their time is fast approaching. It's a denial of sorts. It's a belief that things just keep plugging along.
11
“Emergency responders in the United States typically default to what one research team called a “maximalist” strategy. But as with any intervention, CPR has its own risks: …” This makes my head spin as a cancer survivor who will not undergo treatment if it recurs. “Maximalist” they euphemistically, almost benignly call it? Let’s call it what it is – Extremist – as are so many ‘strategies’, actually just tactics, in the US so-called culture – healthcare or otherwise. It appears that we are finally over the threshold of a state in which every single thought or movement is driven ultimately by a money-lust. These people, at each level, are driven consciously or subconsciously by whatever is likely to bring in money – and as much money as possible – as it has a direct impact on their own paychecks, their own lives, their own needs. Are the ‘resuscitation workers’ compensated based even partially on how many poor souls they resuscitated? If true, that’s a huge problem front and center.
I would like to know how I can avoid these savage and selfish actions, taken under a mantle of health”care”, at any cost. What can I do as an aging, very likely future patient, to escape the clutches of these torturers? You’re not even safe once you’ve committed to Hospice? It’s beyond belief. I’m going to research the POLST immediately, and thank you for that link.
5
Alert!!! POLSt or in NC called MOSt documents give Physicians and hospitals the legal right to make decisions which override patients Living Will or Health Care P.O.A. documents. These documents have the legal authority to deny the family or the pts. living will and do what the doctors/hospitals want to do, including refuse to do CPR or treat the pts. I'm not sure if this is true in other states but I have recently investigated this in N.C. and it's true.
My very old mother went to a new doctor and on the first visit he had her sign a DNR and the NC Polst form called Most. I was outraged as we had all the documents in place and as a completely healthy women I was furious he had her sign a DNR and put it in her electronic record at the closest hospital.
When I spoke with the new doctor he was completely unaware that these documents are legal means to deny prior living will or the health care P.O.A. I sent him the NC statue and he was very sheepish.
Be very careful!
9
@Chelsea It is the patient's own choices and preferences that are documented in a POLST form, not the physician's or the hospital's.
65
@Chelsea NO ONE has the legal authority to override a pt's wishes. Period. The most recent choice made by the patient has the entire authority.
12
@Dr. John, Even if you sign a DNR? Unfortunately, I have known of cases where a DNR is in place but the patient was resuscitated anyway. My sister's mother-in-law was resuscitated even though she was close to ninety and had suffered Alzheimer's for at least a decade. She lived for several years after that in a basically vegetative state, a sad ending that no one would want.
9
Our fear of death is so pronounced in this country that medical intervention is the automatic, go-to option regardless of how old or ill one is. TV CPR isn't real CPR.
My stepdad had some sort of cardiac event while hiking. He was near the top of the mountain where there were facilities, including a defibrillator. A tourist who was also a doctor saw my dad collapse, rushed into the building to get the defibrillator and resuscitated him with two shocks. My dad was one of the small percent that recovers without residual effects. The tourist-doctor did not know that my dad was DNR. He did not know that my dad had a progressive dementia.
Two long years later, my stepdad is still with us, suffering from advanced stage dementia with no clear end in sight. I know I should be grateful to that tourist. But I can't stop from thinking about all the suffering that might have been avoided had my dad been able to die where he was most happy in the mountains during a glorious hike.
If you are DNR, make sure people know. And get a bracelet (or as some people have done, tattoo it across your chest).
119
Um. Yes. I would say I’m afraid of death. I get mad when my favorite tv show is not on. I’d be a heck of a lot more upset if my whole life turned off. Not to mention my loved ones and their suffering which, unlike me, they would actually feel. I, of course, would be too dead to care and on the off chance some piece of me remained in the ether, man, I’d really hate being muzzled and invisible.
I mean. It’s not like we can try it like broccoli and see if we can tolerate the taste. This stuff is permanent! Irreversible! There’s no coming back from death. It’s a one way exit ramp and the train continues with the party on board while your stationary in the dessert hoping they’ll come back assuming you’re even conscious. Not at all appealing to me.
So yes, I concur that I fear death. Undoubtedly I will meet it someday but I’d prefer to be 105, eating a donut, lounging by a pool.
Not to make light of the issues examined here but for me, pls try and save me. Even if my hair is gray and my face is wrinkled.
7
@GWE each to their own.
5
um. Yes, death is irreversible.
No one makes these decisions easily. Too bad you feel the need to disparage those who make different decisions than you.
@GWE each to their own. But be respectful
12
In the opening anecdote, if the family member who found the unresponsive woman had *not* called 911, could that person have been charged with a crime? As it happens letting the stricken woman die right there would have been the best outcome.
3
No. The patient was in hospice and therefore the death was “expected.”
But even without hospice, their metastatic cancer diagnosis meant the death was still expected. In my family member’s case (no hospice), I called the NON-emergency number for our local police department and reported the death. A nice young police officer came to the house, took a report, then had me speak with the medical examiner on the phone. The medical examiner asked me a few questions about my family member’s medical history and was quickly satisfied that the body could be released to the funeral home.
In giving this answer, I do not want to discount the concern that your question identifies. You may well have uncovered an important motivating factor, and possibly one that acts more subconsciously than consciously in the minds of family members.
10
@Richard Schumacher
Not if she was on Hospice and had a DNR in place which is part of the enrollment process.
3
@Gabby K
That is a myth. You do not need to be DNR to be on hospice. The vast majority of people are, though.
Through out this article, all I could think of “first do no harm” and that is how the article ended.
3
Surgeon, since 1982-count me in the, "Only 18.5 percent thought it inappropriate."!!
6
Carefully and lovingly explaining the meaning of a DNR vs full code is something that will likely be required on numerous occasions throughout a prolonged illness. That was my experience.
In addition, careful and constant attention to the orders is crucial as a patient moves from one facility to another (hospital, rehab, assisted living, skilled nursing). Orders that I was informed would transfer, did not. Thankfully we caught this (whether errors, oversights or standard practice I'm not certain) in each instance.
6
I'm a registered nurse. Throughout the years I have seen my share of difficult situations. reality is that people and families cling to life, despite of death sometimes be starring them on the face. how many times I witnessed patients choosing full code despite very, very reasonable medical assessments determining that they should pick another direction? also, families sometimes get in the mindset of no one wanting to"kill" dad or grandpa. completely unnecessary suffering could be avoided by at least considering dnr status. A code blue can go on and on i have seen cases where the family had to be contacted essentially to reverse the code status so the person could die
in peace. very sad , but bottom line most people decide on a full code despite of everything else, therefore the culture of full code by default. someone calling 911 for an unresponsive pt enrolled into hospice just should not have done that. Way more problematic is, however, the concept of partial code. These are the instances where people pick from a menu: I want chest compressions but no reviving meds, or I want to be intubated but no shocking, or I want shocking but nothing else, etc. Not sure whether partial codes are available in every states but aside from a very minute population of patients they should not be a regular choice for the average person. What is the point of restarting a heart if there will no adequate ventilation?
13
It’s fear. Fear of being Sued, by an ignorant and nearly always
“ Religious” Family Member. They have no skin in the game, as they will NOT be required to pay the Bills, or for actual Caring for the Patient. I’ve seen it a thousand times.
The only defense: every adult, especially age 50 or older, must have a properly executed Power of Attorney, for Healthcare. ONE designated person, to make any and all decisions, if the Patient is unable. Make your wishes known, find your Person, and DO IT.
Best Wishes.
21
I'm shocked by the callousness displayed by the author, who writes:
"Her metastatic breast cancer had entered its final stages, and she had begun home hospice care. Yet a family member who had discovered her unresponsive that morning had called 911."
This is written as if the family member who called 911 is to blame. Can you imagine the fear, shock, and/or confusion that that that family member was feeling in the moment?
There's a very real discussion to be had about expanded the duration of life at the end of life. But this sort of misplaced blame isn't helping foster that discussion.
5
A principle of hospice care is to not engage any attempts at life saving efforts. Calling 911 in the instance described WAS the wrong thing to do.
38
The family member should have been educated by the hospice staff that if the patient’s condition changes, they should call hospice so that the nurse can come out and assess the patient.
In my experience, when families call 911 when patients are on hospice, it is typically for 1 of 3 reasons: 1. Poor education on the part of the hospice about how meaningful hospitalization is (or rather isn’t) at the end of life; 2. Profound denial on the part of the family member about the dying process; 3. Some unexpected emergency—e.g. sudden acute bleeding—that neither the family member nor the hospice could have predicted.
23
Exactly.
2
Although I understand the dismal implications of this article, I wonder if it missing some other societal shifts. As of 2019, for the first time in decades, the home became the most common place for people to die--not the hospital: https://www.reuters.com/article/us-health-dying-choices/home-is-now-the-most-common-place-of-death-in-the-u-s-idUSKBN1YF2Q6 .
I suspect this trend continues. Again, I do not wish to contest the alarming numbers presented in this current NYT essay, but it does appear many people are getting the message. Hospitals appear to have their own set of ongoing problems.
2
Many health care workers are in favor of resuscitating everyone because they are thinking about THEMSELVES, not the one in the bed. We just don't let people die (peacefully, especially) in this country.
4
@JoAnne
This is demonstrably false--just read the comments from all the doctors, nurses, and first responders. Most health care professionals I know, myself included, do not want to code a 90 year old with advanced cancer because we know it is a barbaric way to die and the outcomes in this population are abysmal.
The legal environment in which we live FORCES us to code these people when they do not complete directives or POLSTs in advance that specify wishes to not be resuscitated. Being DNR requires people to OPT-OUT of CPR, not the other way around. Read the article's title again.
7
@Caligirl - not in my experience as a nurse. I've even seen nurses discontinue morphine drips on dying patients because we were "killing them." I've had doctors refuse to extubate patients even after the DNR was signed and the family requested it. I've heard some say it was "against THEIR religion", regardless of the patient's wishes.
2
@Caligirl - Be thankful you do not live in the Bible Belt.
2
I'm a hospice nurse. I teach families and staff at care homes over and over to call HOSPICE, not 911 if anything happens.
I add 'it's ok if you forget, just call us (hospice) next". I explain that our hospice nurse and MD can talk to EMTs in the home, remind the family member that this is why the POLST needs to be visible over the patient's bed, etc. We can send a nurse to the ER (often but not always) to help in coordinating comfort care in the ER, if interventions are needed. Our MD will talk to the ER hospitalist on duty.
If there is an apparent cessation of breath and cardiac activity, and the POLST is presented to the first responders, the immediate interventions dont start...and the patient is able to die. Lots of coordination between hospice and first responders is needed.
146
We had these same, very clear instructions from Hospice when my father was dying. Although he never had a cardiac arrest he had several episodes that would have resulted in the ER and probably hospitalization had we called 911. Instead, we managed perfectly at home with the support and follow up of hospice staff. Education of all family and friends about the plan is critical.
40
@mary : Thank you for sharing this. Families need education, not the sort of shame that the author of this article and many of the commenters are dishing out.
12
@mary Thank you. We did not know this was an option. Forewarned is forearmed.
12
We intensive care physicians have a lot of experience with end-of life care. The spectrum ranges from patients who are miraculous "saves" to severely ill patients who linger in the twilight of death. Fortunately, more patients are telling their families about their preferences for end of life care. That "discussion" is the best and most humane solution for all---patient, family and physician. I should know. My Dad was a career Navy pilot who served in two wars and survived two plane crashes. When I asked him what I should do if he became severely ill, he was very clear "if you can't bring me back to the way I was, don't put me in the ICU." Later, as his dementia took over, I followed his orders.
31
Seeing my father at the age of 90 and having advanced dementia and respiratory failure in the hospital, I could not imagine what it would be like for him to have the cracked ribs, pain and suffering from CPR. Had he been alert he would not have understood why or how he got the painful injuries or tubes inserted. It was a relief that the doctors caring for him agreed with me that DNR was not appropriate.
It isn't a case of sick, inconvenient elderly, it is compassion for the last days of someone's life.
13
DNR was NOT appropriate? It's this a typo?
4
@ibap yes, that was a typo. DNR was appropriate.
1
The lady mentioned at the beginning had breast cancer in it's final states and was 90. The family member finding her unresponsive could have just quietly sat and held her hand, and let her go. If you call 911 and there is no medical directive stating otherwise, they will try and "save" the patient. We need more education about end of life care - and it is caring in many circumstances to do nothing except provide comfort.
16
@dairyfarmersdaughter : I'm glad that you can sit at home at your computer and decide what the best response would be for someone else. Is it so hard to imagine that the family member was shocked, afraid, or confused? Please, stop blaming the family!
2
In FL, even with a DNR, if the EMTs are called, the DNR is negated.
2
It's just that people need education. You mistook my observation as blaming. I was in the room as my father had a stroke and breathed his last. I know how hard it is
15
I’m going to get a large tattoo across my chest saying DNR.
9
Someone actually did that, and the doctors didn’t know what to do. It was a real ethical dilemma because...was he drunk and did the tattoo for a lark? Written up in, I think, the NEJ.
6
Just went through a similar experience with my grandpa. He was clearly dying and yet they did every conceivable test, technical exam, and life sustaining treatment even though he was in end stage, final days of liver failure. His last days were spent in a state of exhaustion from continuous poking and prodding and a diet of jello, pudding, and glucose shots to his iv. While laying under an uncomfortable air powered heating blanket that looked like a plastic raft. Not the way I want to spend my last days. Sometimes medical intervention is not the correct path but I feel like we've become a commodity to the medical professionals and the insurance industry. In all things, I am beginning to feel completely powerless in the face of our capitalistic society. Shut up, be a good American and go buy the newest clothes, cars, and other products that are cheaply made but you still can't really afford and let us treat you like a medical experiment so we can make more money off of you and your pain. Ya, so, like, happy Saturday...
17
You can wring your hands all you want but we have to wrest power back from the lawyers on this topic before any meaningful change.
No one wants to lose their license for not resuscitating grandma, and when time is of the essence, no one wants to make the wrong call and get sued.
Just speaking the truth.
21
@bytheway - In the hospital where I used to work, the medical director gave a talk to the nurses and said that more doctors/nurses/hospitals were sued FOR initiating CPR when a DNR was in place (assault & battery - and expensive) than NOT.
1
In MA, by law everyone has access to a MOLST (like the POLST) and Comfort Care/DNR form which drs are supposed to discuss with each patient if the patient desires on which the patient indicates their desires. We as a society must be much more willing to emotionally grapple with death, learn to accept and come to grips with approaching death of loved ones, and respect the desires of our loved ones. By definition to be in hospice means the patient has < 6 months to live. By calling 911, the family member unnecessarily put the patient through procedures and pain (eg CPR for elderly patients often results in fractured ribs). I doubt this was something the already dying 90 year old wanted. A call to the hospice nurse, trained for these situations, could alternatively been made. As painful as it is for loved ones, we have the ability to help provide a good death by holding back and not calling for emergency care.
15
@Patricia L. : We don't know what the family member communicated to her loved ones ahead of time. We don't know what the family member understood of her wishes. Was the person who found her shocked, afraid, or confused? Did they think they were acting on their loved one's wishes? Who knows. But blaming the family member who called 911 isn't going to help.
If the person is receiving hospice care that is all obvious.
9
@Rose Sure it will, if it gets somebody thinking about the right thing to do if they find themselves in a similar situation. “Here is a case where a wrong decision was made. Learn from it.”
6
As a MD for 25 years I can categorically state that this is NOT a new issue. It is interesting that the researcher posed it the way that she did. Often, codes are done at the insistence of the families. They cannot conceive of not at least trying because they feel like it is letting their loved one down some how. And FWIW oncologists are the worst at preparing their patients for end of life. From the time they are diagnosed they have an increased risk. I am not sure if they don't bring it up because they want to keep hope alive but I have uncounted cases where families were so relieved that I raised the issue when their loved one was admitted to the hospital giving them the chance to work through the discussion.
And ask an MD or a nurse about resuscitation and we will almost uniformly decline it.
36
As a nurse—I could not agree more. Well put.
12
This article is addressing two separate issues by applying a story of a patient near death with metastatic cancer to all comers of a certain age. The first topic, having a life limiting disease is a topic related to hospice and good anticipatory guidance by that team. General survival for out of hospital arrests of a certain age is a separate topic. When EMS arrives there often isn’t anyone there to give a good history or know what is going on- they may not know the age of the patient or the diagnoses they carry. I think in some ways it’s a disservice to both topics to review them with hindsight bias.
3
911 = emergency response (i.e., resuscitation).
That families of hospice patients call 911 when their loved one is dying indicates a failure of the hospice program to educate and/or be available to them.
Signed,
Retired physician and former caregiver of three family members who died at home.
66
I am a hospitalist who deals with these situations daily. The agony is so clear when I talk with family called upon to make life and death decisions for someone else, especially when they are unsure about what to do. The emotional stress of the burden to make the "right" decision without clear guidance from the patient keeps the most level-headed awake at night.
My own belief is that whatever decision you make in these situations is the right one. Always. When we make decisions for our beloved ones, with love and care in our hearts, then by definition, those decisions are the right ones. There is no such thing as a wrong decision when it comes from a loving heart.
It is easy to see the truth of this. If I had a stroke, and while on death's door my children decided to remove me from support, but it somehow became apparent that with just a day longer, I would have lived, what would I want for them? What would I say to them, if I could? "Damn you for depriving me of survival", or "I hope you think about your mistake forever"?
Of course not. I would want them to be at peace, and live out their lives with the knowledge that they answered the call of responsibility with a decision that they believed was right and made out of love. We are imperfect beings making imperfect decisions with imperfect data. The perfection comes from love.
Also realize it is the family who goes on. Their process deserves respect. Patients would gladly cede some time for their ongoing comfort.
187
@N Browning This reminds me of my father, who had a stroke at 81 while he was in the hospital recovering from a fall. He wanted to go home but the doctors said-rightly, I suspect- that he was not able to get up and down unaided. He lived alone, after my mother's death. I think, in retrospect, that he wanted to die in his chair, in his home. The stroke changed that. He was immediately hospitalized for the consequences of the stroke and was then in a coma. The coma lasted 3 months and the doctors asked if I wanted to discontinue breathing support. My Dad had left no medical directives regarding his wishes and I was unwilling to let him die without knowing them.So I refused to discontinue his treatment. After 3 months he "awoke" to the surprise of the docs. I thought my decision to wait had been validated but my father was very angry that I had not let him die and that he was now forced to suffer. He continued in a greatly diminished state for about 8 more weeks before finally dying. I don't think he ever forgave me for prolonging his life and, therefore, his suffering.
54
@N Browning Your comment is beautifully articulated. Thank you.
15
My brother and I recently had to deal with this issue. My dad has been married to his second wife (after leaving our mother) but they divorced even though he never moved out of her house. She did come to the hospital every couple days or so after his stroke on Christmas but her dementia and selfishness resulted in her not being there for him. So his children had to make the decisions on his behalf. He never communicated to us what he wanted so we went to his house and looked for an advanced directive and talked to his long time friends and extended family but he never told anyone. Making decisions for him because he couldn’t make them for himself was agonizing. We tried to do what was best for him, what he would have wanted, what anyone would have wanted. Watching him struggle to breathe in a vegetative state and thinking he would die by gasping for air for several days, we decided to put him on a breathing tube. He was on the breathing tube for several days but no improvement in his brain, and feeling it was inhumane, we took him off. She didn’t see him or stay with him in his final days, but I did, alone with him in a vegetative state. Yet she did after the fact tell us that we should have done more for him and we left him there dying. I did everything I could to show up for my father’s illness and death. I wouldn’t change that. But these decisions are mind boggling and are made even harder by difficult family relationships.
34
It's so seductive, this notion that it's fine to withhold care from inconveniently old people so medical professionals can concentrate on more appealing patients who are “more likely to benefit.” But this is the slipperiest of slippery slopes: Once we start retooling medical ethics to countenance “What the hell, let ‘em die,” where do we stop? It's not a long step to imagine YOUR own sweet self in this emergency-room scenario, where you overhear the doctors mutter: “Well, he used to smoke and has other high-risk behaviors, so he's probably only got another 40 good years or so. Let's put him on palliative care and move on to the golden-haired girl with her whole life ahead of her. This is just ordinary death.”
4
Bingo! Well said!
2
As a physician, I can assure you the slippery slope runs the opposite way. The current system is biased toward offering more care than people want at the end of life because conversations about end of life are not had, which is why articles like these are needed. We’re not talking about someone with 40 years of life to live. We’re talking about someone in the last years of their life whose physiologic reserves have become so low that they are unlikely to survive resuscitation and regain any quality of life. The difference between the two is pretty simple.
42
Totally off-point and a over-used rhetorical bug bear. Preferential treatment was not argued here. The point here was whether CPR had a good outcome compared to doing nothing. Fake scary doc conversation or not, I would prefer DNR.
11
I am a retired internist, now 78. I was an emergency physician for 20 years and also cared for critically ill persons in my internal medicine practice. Outcomes from CPR over age 65 are poor. I always hated having to perform this grotesque procedure on frail elderly persons. Out-of-hospital cardiac arrests have particularly dismal results. A small minority survive to hospital with spontaneous circulation following resuscitation. An even smaller fraction of those survive to discharge, and a tiny fraction of those recover to the functional status they enjoyed prior to this catastrophic event. Others have various levels of anoxic brain injury with diminished cognitive ability, unable to return home, admitted to nursing homes or other types of assisted living facilities. Heroic resuscitative efforts are the default because a rare outlier may recover to enjoy a meaningful life. That is, meaningful to the person whose life it is. The figure here is probably in the 1-5% range, but as one reaches age 80, those odds are closer to zero.
I fortunately was able to convince my personal physician to provide me with a POLST. I am a DNR. I am registered with the Oregon POLST Registry with the number laminated on to my Medicare card. It is displayed in my home and scanned into my electronic medical record. Some would argue that I am not sufficiently frail to merit having it. Good luck with that. If I am assaulted with with unwanted CPR, my attorney is prepared.
25
I completely agree except for the absurd comment about CPR on persons over age 65. The writer then goes on to further describe this group as largely frail. Like virtually all the 60 persons I am constantly around, we are fitter and more active today than when we were 20.
6
@From Where I Sit Wow, I just turned 65 and have never been seriously ill in my life. I'm active all day long. My husband is 68 and on alternate days, runs and does a serious weight-lifting program. We used to teach dance and had a very fit 83-year-old student who was in better shape than much younger students. I gather he carried on dancing for at least another 10 years--I saw an article about his dance group in the local paper. We are NOT all fragile at 65. What an absurd idea.
5
My mother-in-law went into cardiac arrest at home, alone. Right before she blacked out, she had the good sense to call 911. They broke into her house and started CPR. She flat lined again on the ambulance and she was revived a second time. She flatline again at the emergency room.
She had the blockage removed and at 3pm that afternoon she was alert. The first thing she said when she woke up was "where is my purse". The second thing she asked was what had happened to the preserves she was working on. We adore her.
Thank God, truly, that the paramedics didn't see "an old lady" but rather a person in need of saving. Thank God the hospital didn't see her and think "oooh old lady" and thank God they brought her back to life. Five years later, she is in Florida right now enjoying life. We will be seeing her in two weeks. She has watched her grandchildren grow up. She has traveled. She has found love. She is living a full life.
As she should.
40
@GWE
You left out something very important.
How OLD was your mother-in-law when she had her heart attack?
This article is talking primarily about folks older than 80. we let my mother go this year. She was 89. She wasn't traveling. She was watching her great- and great,great-grandkids being born. She was married 67 years, but terrified Dad would pass before her. Together, they prayed the Lord would take her first. On a Monday in August, she had a cough. On Friday, She went to the hospital. Sunday morning it was apparent that either extraordinary measures would be required or she would likely pass. She was still participatory in the last rites Sunday afternoon. She passed sometime in the early AM of Wednesday morning.
Might she have had more days, yet? Maybe, but i doubt they would have been good ones. I question the decisions made, not because they were the wrong ones, but because if you DON'T question such decisions it really does mean you made the wrong ones. You should be uneasy with such choice. I am glad it worked out well for your MIL--but for folks over 80, it rarely does.
36
@GWE I am assuming you are using the term "flat line" loosely - that is one of those unshockable rhythms with little to no resuscitation possible.
19
She was 76, so point well taken. But still....
... and I don’t know right name they said she went into cardia arrest and her heart stopped three times. When they called us she was on the table being shocked....they used paddles on her three diff times. She was bruised for weeks.
6
My mother is 98, in relatively good health for her age. She has very specific DNR/MOLST orders posted clearly on refrigerator. We, her children, will respect these orders; besides respecting our mother, we are all healthcare providers, and have seen the ravages of ill-advised resuscitations.
My in-laws are both 85, in poor health, with multiple chronic illnesses. They are adamant that they are “full codes”, everything must be done in case of an arrest. Their physicians have never explained the consequences of resuscitation they will likely incur. They refuse to believe what we tell them; their doctors “know more”.
79
@MM If you are a healthcare provider, you probably know that that DNR/MOLST can get lost in the ambulance or misplaced in the chart between the ER and the inpatient unit (my mother's did), and that nursing homes don't have to respect the MOLST any more than they do your stated wishes. Including SNF stays for rehab. When you sign your mom in, you will be signing away many of her rights.
I am in healthcare and witnessed the system break down in ways that I couldn't have anticipated even after 30 years in the business. I built in contingencies and coverage....I lost count of the number of times it wasn't enough to counteract the failures of the health system.
Keep those documents; just don't think they are a shield against misfortune.
And remember that you cannot sue a NH for bad care, just bad outcomes. Meaning dire injury or death. I am quoting my elder care attorney on that one.
7
@MM
Are you aware that the MOLst document gives the doctor the rigth to make all decisions for your mother regardless of what she or her family wants.
5
@Chelsea That is incorrect. The MOLST or POLST documents the patient's own choices and decisions; it does not permit a doctor to override them.
74
I do not know the answer but think about this one issue with universal health coverage.
1
This and universal healthcare are in no way linked.
12
I saw the way it was handled in the UK with my mum, and I saw how it was handled in the US with my in-laws. I’ll take the NHS any day.
10
@J Goldman I live in Germany, which has Universal Healthcare, and there is good money to be made with storing breathing corpses, even against the wishes of their relatives. This also applies to poor families (because "Universal"), and in fact as a money-making device works better on poor families who often cannot afford proper legal advice. Back when Universal Healthcare was introduced in Germany , most of these cases would not have been survivable in the first place, so the healthcare system did (and does still) not quite know how to respond. This says nothing about if CPR is good or bad, or Universal Healthcare is good or bad, but if you are only about to introduce Universal Healthcare, as the US would be in the unlikely event of a Democratic victory, then you might as well plan it in a way that avoids wrong incentives. In that way I would say the two issued are indeed linked.
1
An informative article. It describes the doctors and ER personal to a tee. God like, omnipotent and omniscient. I agree with the EMT who advised his wife to go shopping and leave him face down and forget calling 911.
I can't imagine being bought back to life after dying to face a horrible existence, though I may not be cognoscente of it.
Do no harm is and should be the main concern of the ER people.
7
I'm almost 62 and have surpassed the age of death of most males in my family line, all died of heart attacks.
I have no tattoos nor have never had any desire to get one either. However, after reading this article, I'm considering getting one blazoned across my chest - DNR!
5
I am a Cardiology fellow and face these difficult scenarios everyday. People without advanced directives suffering away in the ICU for many days before going into cardiac arrest. These settings are brutal. The outcomes are extremely poor.
Some patients and families want "everything done" despite all the education physicians provide regarding the poor prognosis. Rarely are the outcomes unpredictable. Because we can do all sorts of interventions to the human body doesn't mean we should.
There should be dignity even during the dying process. Please have honest conversations with your loved ones. Many, even with dire medical conditions such as chronic heart disease, lung problems, severe dementia and poor quality of life remain in denial. Death is inevitable.
28
The only hospital in my community is Catholic-affiliated. It states on their website that they will not honor DNRs or similar, because it is their mission to "preserve life." Patient wishes are completely ignored in favor of religious belief. As I get older (I'm 67) I find this bothers me a great deal, and I will probably need to sell the home I love and move from my community of friends to a town with medical facilities that will respect my wishes. I have considered suing the hospital, but in this era of "religious freedom" I'm sure it would be pointless.
29
@Ms. Pea That's why you tell everyone, "Do not call 911 until an hour after I'm dead."
13
@Ms. Pea
My advance directive forbids Catholic health care unless there is no other alternative. Fortunately, in my area, we have access to alternative secular health care.
15
@Ms. Pea
I believe you since you say this appears on their website, but that is perhaps limited to that particular institution, not all Catholic institutions. There are several very good Catholic hospices (e.g. Providence TrinityCare in Los Angeles). I have never had an issue with a Catholic hospice or affiliated hospital not respecting my patients' desire to be DNR and have had plenty of my advanced cancer patients die in Providence-affiliated hospitals on inpatient hospice or comfort measures only, both of which situations would involve the patient being DNR/DNI. In fact, Providence has a well-known palliative care program headed by no less a palliative medicine luminary than Ira Byock, MD.
3
When in doubt, err on the side of life. Ageism is real, and an emergency is not the right time for medical personnel to decide whether someone is worth resuscitating or not. I will always be grateful that someone resuscitated my 87-year old father. Viewed scientifically, it didn't do much for his life, but it gave us an extra month to say I love you and goodbye. That was priceless.
5
@Carolyn Clark
When in doubt, respect the wishes of the elder!
I see it as Ageism when we don't honor the elder's DNR instruction. It is the ultimate personal right - the right to control my own body, including whether or not you restart my heart after I am dead.
CPR, by definition, is done AFTER A PERSON IS ALREADY DEAD. I am not afraid of death, but I AM afraid of languishing in a hospital with strangers messing with my body.
If I'm ALREADY DEAD, then I'm headed towards the light - why would you bring me back from that, only to suffer for a few days and THEN die (or, worse yet, linger with brain damage and broken ribs). I watched my dying mother "see" the light before her final breath. She was filled with happiness and joy, then slipped from her body.
Because of my work with elders, I've been honored to know about 120 elders as they transitioned out of this body and into death. I speak from this history of "real" experience.
29
@Carolyn Clark If your father was otherwise healthy or didn't express the wish to be allowed to die, then that's great. But to go against the wishes of someone who specifically says to let them go is immoral.
14
@Carolyn Clark - It appears that regardless of the fact that you prolonged your father's death, you thought it was worth it for YOUR benefit. I hope none of my loved ones decides to do that to me.
9
Sometimes the human race needs to think like the rest of the animal kingdom: Death is essential. Learn to accept it. Any bird, mammal or reptile will try to stay alive, but beyond a certain point, they let go. This is something humans can learn from. Simply because my heart continues to beat, if I am "brain dead", I would rather be nothing. This is why I have a living will.
22
Drs. and eR rooms perform CPR on patients who suffered a heart attack, and who were technically brain dead by the time they arrive at hospital.
Without detail here, a friend of 42 years of age, Scientist, Director of a National Laboratory, suffered a heart attack after returning from DC - only to be kept alive with heart medicines that pumped his heart, while his other organs died one by one.
He left the world during the time he got into a car at an airport and was discovered unconscious ( he was driving) at a fork in a highway.
If he had had any knowledge of that he might suffer death, when changing his will, he should have included a clause about not resuscitating him, if brain dead.
When I think about this, it cost the County, his insurance, his laboratory (government - tax funded), and all of his friends a great deal of money.
When the electrical energy of the brain is off, in the cortex (not the central nervous system), that should be considered a time that the person has left the world and to discontinue pumping medicine, water, and air into the person.
12
@RR
Of course you would resuscitate a previously healthy, active 42 year old and continue life support until it is determined that he is brain dead. Your example has nothing to do with this article which addresses the appropriateness of performing CPR on individuals who are very frail and nearing end of life.
5
@Riley2
No, in fact, he was NOT healthful. That is the detail. This was more than 40 years ago. He was NOT doing anything correctly, including taking blood pressure medicine. He was abusing contraband substances, unbeknownst to many.
The pathologist who performed the autoposy found his heart in such disrepair, it fell into pieces when removed from the cavity of his body.
Additionally, he had genetic heart disease.
When I wrote, had he known he was going to die, what I should have written was had he taken the responsibility to know that he was going to die.
He was a very good friend.
In the IC room, he was naked, with a diaper, and on display for all the visitors of his entire life. He was a respected scientist.
All the drugs did is cause his body to heave about 12 inches off his bed.
He WAS brain dead. He had no oxygen for more than 14 minutes, from the time of the discovery that he was unconscious and adding the time when he probably died while on a major highway. His guest helped drive the car to safety, from the passenger seat.
He was kept alive only in order that all of his organs die one by one. A painful way to go.
6
All of this is so straightforward in theory but incredibly difficult in practice when it is someone you love and not a doctor-patient relationship. My mother was a healthy, energetic 79 year old when she went into cardiac arrest and my dad called 911. When I arrived at ICU, doctors had put her on ice and had her on breathing machines. What ensued was a seven week ordeal where doctors couldn’t find evidence of brain death or severe heart damage. After five weeks we were elated when she regained consciousness—she recognized us, responded with her eyes—but it was soon clear things were very wrong. Despite efforts she couldn’t speak or move anything below her neck except her toes. Her head and neck were spasming. We ended up having to move her to hospice and to make the traumatic decision to remove water and food to let her go. Nobody prepares you for these things. With hindsight it was horrible and we never would have put her though it all. But it is honestly impossible to imagine not having tried everything in our power to save this woman who loved life. We, the nondoctors, need to talk about this issue more.
121
@Janet
I am sorry for your experience and grateful you shared it.
26
@Janet
You did make the right choice. It did not have a happy ending for your mother, but if she was healthy and energetic it very well could have and you cannot know beforehand what will transpire. You were given the grace of some time to prepare for her passing, as was she. We would always like a happy ending--but we are rarely given that. Death is a strange grace given to humankind. There are no good ways of passing, only different ones.
Be at peace.
22
I am almost 60 years old and have enjoyed being in amazing health and have the vital signs of a person in their 30's. I have always thought that I would live to be 100 years old and never thought I could die. That has all changed for me in six weeks time. I was in a freak accident and now have multiple rib fractures, nerve damage and a collapsed lung. I was in the hospital for nine days, discharged and re-admitted for another five days with liver damage. This is the first time in my life I have ever thought that I could die (however my vital signs remained stellar throughout). It has been a very traumatic experience to be hooked up to multiple machines and several days infusion treatments. My hope is to recover by the summer to start lifting weights again; fingers crossed!
This is the first time I have ever filled out a Advance Directive. That was a very difficult thing to do but I would not want my loved ones to have to make this decision for me. I did find all of the tubes, needles, endless testing and HORRIBLE hospital food (ordering a BLT is not a crime!) to be traumatizing. To do this to a frail elderly person with no hope of a good outcome- I can't imagine the cruelty and it pains me to think about it.
32
When I was working through the system with my elderly father. It was a battle to avoid unecessary practices. While I miss my father deeply - watching him survive numerous interventions when he clearly wanted to go has caused me (because it caused him) deep pain.
And, I was not an uninformed advocate. He had a medical directive, I was there as his advocate, and was able to effectively avoid CPR (which, if done correctly, usually breaks ribs). I was able to avoid some other interventions (feeding tube, etc.).
But the list of potentially life-extending interventions that can be useful and effective (but, often painful or otherwise unpleasant) is long. In an elderly man with many other medical issues - these interventions cause a loss of dignity and pain at no tangible gain.
We need to learn to talk about quality of life in more meaningful ways.
And, for the love of quality of life - stay strong so that you don't suffer a fall!
18
Forget about Do Not Resuscitate documents. I want to sign a Do Not Hospitalize form.
43
As a nurse , I say C.P. R.for out of hospital arrests in the elderly is a grossly overrated intervention.Life is about quality not quantity and preservation at all costs is unethical at best and inhumane at worst. Think about what you are requesting for your relatives.
34
POLST’s and DNR’s are great in theory but they are not pasted to the patients forehead. When a patient experiences cardiac arrest time is vital. No one is calling their lawyer or primary care physician to see if advanced directives are in place before starting CPR.
My 89 year old father with dementia and heart failure coded in the middle of the night while hospitalized and was resuscitated and placed on life support. He had executed advanced directives with his elder lawyer but since his hospitalization was not considered life threatening no DNR was filed when he was admitted.
When we arrived at the hospital at 2am I told the nurse we wanted the tubes removed. She was shocked. I asked her “Why on earth would you resuscitate an 89 year old man with dementia and heart disease who would have otherwise died peacefully?”
I could go on and on and include more gruesome details about how this all played out but I think I made my point.
417
@MK McC
I am sorry that this happened to your father and your family. It’s a sadly familiar story to me.
Hospitals need to make it easier for nurses and doctors to honor patients’ DNR wishes. My father (demented, 91 years old, and 92 pounds at his final hospitalization) was given a hospital bracelet that said DNR, and a large sign on the wall above his bed read DNR in block letters. This does not appear to be standard practice yet, but of course it should be.
People with strong feelings about not being resuscitated can also have “DNR” added to a MedicAlert medallion.
I wish the POLST form had been explained earlier in the article and in more detail. Short of a tattoo, there isn’t much else we can do, unfortunately.
96
@MK Mcc This is the fault of the hospital The DNR/DNI should be addressed for any hospitalization
46
@WJ yes. Every admission at our hospital requires doctor order for status with comment on how information was obtained. Sadly, I think many admitting providers simply click the full code box. It's not something you want to be wrong about from a legal standpoint.
30
My DPAs, DNRs, health care proxies, family and a very specific letter of my wishes are filed here with both ambulance companies, both hospitals, both groups of doctors, and my dental providers. I keep a copy in my purse. A sort of 'break glass in case of emergency' large envelope is on a few walls. And there are others who get them. I update these orders and again distribute as needed.
This is equal parts of not wanting to live when I'm obviously dying and an act of love so that no one feels badly about letting me go.
I'm about to check out the Polst site. These articles are so very important.
10
I couldn't find the edit button, so I'll add this: As careful as I am, it's clear that Polst adds another option for me.
It would be a good thing if everyone considers some form of these documents when they become of legal age. At 65 and ill, it's very important matter.
Thanks for "The New Old Age." I always learn something from them.
11
I was a volunteer EMT in New Hampshire at a small rural department for several years during which time I performed CPR on a number of obviously dead people. In one case it was a 20 minute ride to the hospital where a physician pronounced the unfortunate old woman dead. I could feel her ribs cracking as I worked but the protocol was the protocol. I've told my wife that if she discovers me down on the floor to please go shopping and let me die in peace. Forget 911.
308
@Walt I agree, if in doubt do not do anything to me. I have signed all the papers, walked them to every single doctor I see, and every hosptial. My doctors and lawyers cards are in my wallet so maybe someone will try to contact them if they do not allready have the signed forms. Just let me lie down for a hour or so. Then do NOT CALL 911, call my doctor FIRST. He knows what I want. I am a nurse and have seen almost everything a 1000 bed teaching hospital can do to keep you alive. You would be amazed, and also amazed at the enormous cost.
60
@Walt, that’s what I was thinking about when I read the article. Why don’t families let their elders go in peace? Panic may be the main explanation. Fear another (for good reason). Pressure to ”do something” when others are present and looking for things to blame others for (I have lost enough family members to know how that works). I get it. But if I were with someone who I knew did not want all that at the end of their lives, and they had a heart event, and no one else was around, I wonder whether I would be able to let them pass, Not call 911. It would be an immensely difficult decision. But I have been part of that decision before.
One of my parents, who was terminally ill and beyond treatment options, was brought home from the hospital to die uninterrupted, which is what happened. Death happened suddenly, with family around, and without apparent pain or fear in the face of the dying. The heart stopped.
30
@Walt I am a nurse. I worked in brain injury and I saw what happens when people are "revived" more than a short time after suffering cardiac arrest. Anoxic brain injuries are horrible. I told my husband if I come home and find him unresponsive, and I have no idea how long he has been down, I will leave the house for 30 minutes or more. I know he would be horrified to live his remaining days with an anoxic brain injury -- he agrees. And I have told him to do the same to me. Obviously, if one of us witnesses the other collapse, that is another story. But medical technology has gotten very good at reviving certain patients. The brain, however, still does not do well when it is deprived of oxygen for more than a few minutes.
31
Does DNR mean anything, or do you need legal aid to enforce it? Families have to be on board - hopefully nearby - for both that, and/or voluntarily
stopping food and water.
2
My direct wish is not be resuscitated. At 82 years. I made a notarial document in that sense.
8
My mom fell at her senior apartment and was not reported to anyone for at least 15 minutes. She was transported to the hospital and it was determined that she would not survive without a triple bypass. She was 85 at the time and I was not thinking about her overall quality of life only the near term. Biggest mistake of my life. She got the bypass and within weeks she was in full blown dementia and live in a nursing home with “ memory” care. For three years until all her life savings were exhausted and she died two weeks after being approved for Medicaid. I have not been able to forgive myself for not only allowing her to suffer thru the operation but the time in the care of others whose only job was to ensure they got all of her money and then treated her completely differently. My wife and I have dnr and have spoken about this extensively. I don’t think it’s the doctors or nurses or even the paramedics fault but that of the insurance company that will not cover a doctor who make a good faith call about life and death but will be happy to pay to keep someone alive while they suck the premiums out of their bank account and then drop the insurance faster than a lie comes out of trumps mouth
52
@JD - reminds me of the "death panels" that prevented doctors from being reimbursed for end of life conversations with patients.
8
Thank you for telling your story and so sorry this happened.
12
Everyone who attended her got to bill her insurance for their time. That's the name of the game in our current system.
20
Get a healthcare proxy and make sure your proxy and doctor have it. Besides CPR note, think about no feeding tubes provision. Ramming a feeding tube into an elderly person can be equally disruptive and futile. You make the choice now so years hence your relatives do not have to assume the responsibility. These provisions have nothing to do with euthanasia. Every moral code on the planet allows for simply choosing not to receive a medical procedure.
16
It is mostly the families that force physicians to do futile interventions. We are forced to do cpr, intubate, and dialyze 90+ year olds by family members who say "do everything". We have to torture these patients to death, or else the families threaten lawsuits and complain to administrators who don't care about much else than money.
24
@JB If you ask a family "do you want everything done" of course they ll say yes.
If you explain to a family that your relative can have a peaceful death,with family sitting around or an attempt....(which will probably be futile) to save with people pushing up and down on a chest, the answer would probably be a resounding ...No.
Physicians need to be more truthful about potential outcomes and stop using medical jargon when families are being asked these "big" questions.
11
Thank you for this article. When my mother at 83 had a massive stroke 15 years ago, she could speak well enough to tell the EMTs arrived: "just let me lie here." Of course they didn't, and so began almost three weeks of unnecessary suffering in a rehabilitation facility that kept assuring me, "Oh, she'll recover." When she finally returned to the emergency room, I had a complete meltdown right on the floor and shouted, "For God's sake, stop torturing her." That finally placed her in palliative care where she refused further treatment (one doctor still said, "Oh, she's just depressed." Nonsense.)
Get yourself an ironclad healthcare directive that allows your health-care surrogate no option for prolonging life if you're over 80. It will save a lot of suffering.
28
@Wiltontraveler If she wanted to be left alone, I'm wondering who called the EMTs? Sorry this happened to her.
I think we’re having the wrong conversation with patients and families. When encountering a sick, frail person— we should NEVER ask “do you want us to do everything?”
To our patients and their loved ones, that question means, “ do you want us to take care of your mother, or toss her in the corner?”
Of course we should do “everything” for all of our patients. Everything, that is, that will help them. In the multimorbid 85 yr old nursing home resident, “everything” looks a lot different than it does for the robust 85 yr old who just collapsed on the pickle ball court in V fib and got great bystander CPR. When we ask worried and grieving families, “what do you want us to do?”we abandon them to guilt, to living with the thought that they either “pulled the plug” on grandpa or “tortured him”. It is our duty to help our patients and families navigate this challenging time.
That said— one point that I try to gently bring loved ones to is this— if your 90 year old grandma collapses the day after cheerfully serving thanksgiving dinner for 14 people—do you think that maybe, just maybe, that would be a good last day? Better, perhaps, than 2 weeks in the ICU and a few more in the nursing home before being permitted to move on? Personally, I hope to fall over somewhere in the high Rockies where I won’t be found til spring....
Lastly, as you scan these comments, look for the ones from nurses. They are the wise ones.
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@Doc Whiskey
Agree with you on the nurses ... and your comments, Doc, are darn good too.
The 85-y/o comparison especially well-stated and enlightening. People-- professionals and families, have to think and act in realistic terms.
14
@Doc Whiskey - My son's mother in law had a PhD in nursing. She suddenly developed a lot of fluid on her lungs, and within a few days was discovered to have diffuse cancer of the omentum. Doctors quickly started chemo before she stopped them and adamantly refused any further treatment. She died ten days after diagnosis. She knew too much to opt for treatment.
23
@MegWright
Nurses know. Sorry for you son's loss.
10
When I get to that point I am going to have a tattoo on my chest: NO CPR. Let me go in peace.
4
“In 20 years, people will say: ‘Why do we do this? It makes no sense,’” Dr. Ouchi predicted. “First, do no harm.”
We talked about this as a country years ago and Sarah Palin and McCain decried 'death panels'.
It should be law that every person have an advanced directive that states their wishes. Default CPR only lines the pockets of the medical system and, as the article states, diverts resources from those who need effective care.
15
I am still haunted by the 4 AM call I received from a patient’s son that the EMS was performing CPR on my dying patient. He was 90 with metastatic cancer and was enrolled in home hospice. The son was visiting from out of town and panicked, calling 911 instead of hospice as is usually recommended. When the squad arrived, the DNR was no where to be found and the squad started resuscitation. I told the fire chief that the patient was DNR and to stop CPR, but he informed me he needed to SEE the DNR order before they could stop. The son reached hospice who emailed the order and finally, the patient was at peace. The hospice was at fault for not having the DNR visible but as a society we have paid a high price for this default practice of trying to cure death; the cost is loss of individual and professional autonomy in exchange for risk management and derrière covering. I am also distressed but not surprised that my colleagues are so clueless at recognizing when resuscitation is futile or detrimental. Common sense and compassion have gone out the window and we all suffer the consequences.
25
I don't understand. In this case the poor patient had begun hospice care, so why did the family member call for an ambulance when she was found unresponsive? Don't blame the medical professionals for this one.
10
If we want to know why Medicare is in trouble financially, then we only have to read about interventions such as this one--the resuscitation of woman in her nineties with metastatic cancer in the ER of an extremely expensive hospital. It would not be appropriate in this article for Paula Span to disclose the bill for services rendered by the Brigham, a Harvard and Partners Hospital that is among the highest cost hospitals in the United States. We have an individualistic ethos in the U.S. that values the individual more than the community, but Medicare is a limited resource, and when large sums are spent on prolonging dying, then there is less for future enrollees. Those who advocate for Medicare for All should consider this reality.
36
@Moso - Not to mention the waste of time and resources in the hospital. And we wonder why doctors and nurses are burned out.
8
We live in a warrior society. Americans believe in fighting as an essential right and inherently expect battling death is a good. those with wisdom would understand death has a place and cannot be denied, ignored or wished away. We need to dignfy final moments as a society. In other places and times, the dying last words were prized. People composed poems to be captured as their last spoken utterances. Now, we have a room full of strangers rushing about with tremendous urgency and there are no last words. As a nurse and a certified health care ethicist, this issue is one of vital importance as we consider how to manage health care for a nation that spends the greatest amount of money in a lifetime on the last six months of that life - while millions go without basic health care services. But speaking about this inequity is yet another taboo.
43
@Marilyn Mitchell
Thanks, you write that, "for a nation that spends the greatest amount of money in a lifetime on the last six months of ...life - while millions go without basic healthcare". That sums up the oxymoron of American healthcare.
The populace is either extremely stupid or too gullible to acknowledge the deep problem, we spend more healthcare dollars, these are monies that all Americans pay to purchase access to healthcare than any other nation but with worse outcomes or no access or extremely limited access. The fact is that these monies are gobbled up by the very providers, the healthcare insurance industry, hospitals physicians pharmaceuticals, and medical devices. Sadly, we are happy with our exceptionalism.
8
A few years ago, I was the health care proxy for a friend with terminal cancer. He had a fully notarized DNR which I made sure his doctors and our local hospital had on file.
Interestingly, during the last week of his life, his doctor kept the chemo going. He was miserable but thought the “ doctors knew best.”
Upon hospitalization, a very young hospitalist-doctor notified me and asked about the DNR. He explained it all to me again and told me what to expect. He was compassionate, helpful and told me death would come that day. Clearly, he was up-to-date and respectful of end of life wishes.
And death enfolded as my friend specified.
Several days later at the reception after his funeral, his older doctor found me and said, “ He didn’t have to die that day...we could have kept him alive for another two weeks.”
Needless to say, I was speechless.
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What is very enlightening is the stratification of the comments here. I, like many of the commenters here, am a physician. If you look at the comments from physicians, nurses and first responders as a group, most of us fall into the DO NOT DO THIS camp. Changing the system to address this reality is hard. Many non-medical people have completely false impressions about how often this is successful. Answer: rarely. Legal ramifications, threats, lawsuits and ethical questions make this process very hard to stop once it begins with that 911 call. It may should harsh, but perhaps the answer is to flip the tables... if you're elderly and want absolutely everything done, YOU need to wear the bracelet saying so. Perhaps the default position is to not start CPR in anyone over (pick an age) and only do so if their express wishes are noted on a charm or bracelet they are wearing. You could call 911 for a person down or in distress, but if they're over 70 (I picked an age), you wouldn't automatically start CPR unless those express wishes were known.
35
@Skruggs,
When my brother-in-law was terminally ill, and my husband was with him, I researched advanced directives, DNRs, etc, and was shocked by the results I uncovered. The one I recall most vividly is that a majority of doctors — upwards of 80-90% I believe, do NOT want to be treated as they treat their patients at the end of life, YET a majority (about 2/3 as I recall) state that they would ignore a patient’s DNR, advanced care directive, etc to administer CPR and other lifesaving technologies, even futilely. I can’t recall the reason. But I do recognize the hypocrisy.
9
@Dr. J
It is good to know that in USA DNR is available as a choice. In India,a Supreme Court verdict has allowed advanced directive but still no clearcut guidelines . From our scenario in India, I can say that behaviour pointed by you is not hypocrisy but a lack of defined protocol where a doctor finds it better to err on side of caution than to risk a career damaging litigation. I would say this is a nice initiative of NYT to publish this article as policies for DNR, accepting death, impact of litigations on cost of care, etc. need to be discussed by society more than by medical personals. Medical professionals don't legislate, politicians do and politicians listen to voters.
3
@Dr. J - When my 89 year old dad had a massive stroke we thought he wouldn't survive, the entire family was in agreement with his written wishes not to have extraordinary measures taken, including feeding tubes. His doctor refused to accept that, and kept after us for 3 days, saying "Don't you at least want to
TRY to save him?" He ended up guilting us into allowing placement of a feeding tube. My father lived another four years, paralyzed on half his body, unable to talk or eat, and with a short-term memory of about 30 seconds.
We were equally adamant about honoring our 95 year old mother's wishes as she was dying of congestive heart failure and kidney failure. But every time we tried to talk to her doctor about putting her on Hospice, he'd turn on his heel and stalk out. It wasn't until that doctor went on vacation that his replacement took one look at my mother and demanded, "Why isn't this woman on Hospice!"
12
Thank you for this article! I knew this was going on, but rules vary from state to state. It's hard to ensure that your wishes will be carried out. Following your links, I was ale to find, in just a few clicks, a legal form for durable power of attorney for health care that will hold up in my state. Can't thank you enough. I have a family member right now going through unimaginable stress caring for her aged mother, because no such form existed. Keep talking about this; it's vital.
14
I finally got around to making my “living will” and healthcare POA when my college student daughter made hers. We all piously talk about our elders needing to do it, but none of us know what fate has in store for us.
I made sure the notarized document is on file with my local hospital system and scanned it to everyone in my family, as well as telling them the location of the original.
7
You need a dnr on your refrigerator. Having the forms on file at the hospital/doctors is not enough. Ambulances and paramedics don’t have that information on file so without an on site dnr, they will start CPR. They don’t have time to sit down and read a POA, which is a several pages long document.
14
@S Turner
There are only two ambulance companies here. So it was easier to sent my documents to them. They are on my fridge, too. I added a bullted point letter to ensure my wishes are easily understood and yet backed up by the documents.
4
Anita, I’m in good health and not really elderly, so I don’t want to be reminded of my mortality every day, along with my shopping list and wedding invites.
I feel pretty good with just being very vocal about what I want. It may not work out, but hey.
The purpose of medicine is to save lives. Unfortunately, because of the way the system works, the effect is to unnecessarily prolong deaths. We will all die one day. The quicker, the better. No point in dragging it out.
29
Both my parents had DNRs posted prominently in the kitchen. My father had lung cancer, my mother had Parkinson's. Neither wanted to be left vegetating in a hospital bed. They were clear about their final wishes, and wrote a signed statement detailing how they wanted to be treated during their last days.
I didn't see any reference to DNRs, or patients' direct wishes.
I do understand a physician's moral and ethical responsibility to preserve life. Doing nothing while a patient you don't know anything about dies cannot jibe with their oaths.
Durable Powers of Attorney over health care, detailed wishes, and DNRs are essential. I was able to enforce my parents' wishes because I had the Durable Power of Attorney, the DNR, and their signed statements of their final wishes,
25
@Tenkan From the actual published study abstract: "Overall, 36 of 543 (6.6%) CPR attempts were undertaken despite a known written do not attempt resuscitation decision; 14 of 36 (38.9%) clinicians considered this appropriate, 9 of 36 (25.0%) were uncertain about its appropriateness, and 13 of 36 (36.1%) considered this inappropriate." In other words, about the same proportions of physicians thought it was appropriate to start CPR despite a known written DNR (39%) as thought it inappropriate to start CPR with knowledge of a written DNR (36%).
2
@Dana Broach
I understand.
When a person in hospice care dies, the hopsice nurse handles everything. If the person dies without hospice, then have all the documents ready for the EMTs so they don't resuscitate. It's more traumatic without hospice, because the police will have to investigate the circumstances to make sure there was no foul play.
At any rate, the family has to be the insistent advocate for their loved one.
If the person is not with family, then all bets are off.
3
Yes, and when we see that death is near and want to talk the family into focusing more on comfort at the end of life, so that the elderly person has some dignity at the end, while perhaps surrounded by loved ones in a calm environment, we get the common "do everything". I even had families complain when I used the work "torture" once.
It is not the staff wanting to do this, I guarantee you that. No sane doctor or nurse wants to resuscitate someone very old and clearly dying.
It is the families who insist and even threaten, to make sure "everything is done", because the dying person "is a fighter" and "wanted everything done".
So, we intubate, resuscitate, then have them with vital signs, but frequently not much else, on life support, while the families take their time to understand that no one lives forever.
I once had the family of a 103 year old insist on a tracheostomy, to have her live even longer hooked up to a breathing machine in the nursing home. I am not kidding...
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@supereks 104, that is soooo sad. your comments are right on the money.
5
The thing that amazes me about this article is that everybody asked other doctors but nobody asked the patients or potential patients. A survey of the attitudes of people in their 80s and 90s would help in decision making. My experience as a doctor for 50+ years is that very few older people want treatment if brain damage and dependency is a possible outcome. Facing a major operation many will raise the issue unasked and say "whatever happens, I don't want to be a vegetable. One doctor in this article asked about the ethics of not starting resuscitation. Surely it is unethical to start trying revive an unconscious person who did not want CPR. Since we can't ask the unconscious individual their wishes, knowing what the majority of the same age want should be our best guide.
35
If family members knew the damage that CPR can do - broken ribs, bleeding into the chest, lung injuries - they wouldn't be so eager to call 911. And anyone at home who has an advanced directive needs to HAVE IT BY THE DOOR if the EMTs come; otherwise, they will go full-court press. That's cruel.
59
You need a dnr posted on the refrigerator. Paramedics don’t have time to read a multiple page document.
6
@Anita Larson Or on the back of the front door. They told us that was the other option, if you don't want to be looking at it all of the time.
3
What happened to this poor 90+ year old woman is nothing less than torture and abuse masquerading as "care."
The only thing certain about it was her death and an accompanying set of large medical bills.
43
@Tom You are correct, but the entire thing was initiated by a family member calling 9-1-1. The problem is that mistake of calling for help. Help involves 'doing everything' once you've called. Everyone in the family needs to know not to do that, particularly if the older person has a known fatal disease and is on hospice care.
Abiding by the person and family's wishes 'not to do anything' requires that you NOT DO ANYTHING when they start to pass away. When asked "what were we supposed to do then?", the answer is "NOTHING". Sit with the dying person and hold their hand. Don't call the Fire Department
114
You can also call 9-1-1 and specify "comfort care only". This can be specified in the advance directive. That way if someone is suffering a stroke or some other episode that may not result in death in minutes, the family and patient can be confident that the patient will be medicated and comfortable until the end.
7
@Tom , you are right, I've had a long and good life, let me die in peace.
7
My mother at 89 had had 4 operations involving stints to move blood from one leg to the other. In rehab she slipped and fell and hit her head so they stopped the blood thinning medicine. She broke her left elbow in the fall and Lee Memorial hospital in Ft. Myers FL was going to replace her elbow. (Billed $85k and accepted $11k, another crime in my eyes.) They informed her and me that they "lift the DNR" for all operations. I said that is not her wish and they responded "we know that because we spoke to her but it is our policy." She survived the operation and when we took her to an orthopedist in Maryland he said at her age and health they would have never put he through that operation since she would have had full functionality with her right arm. At a doctor visit checking the circulation in her left leg he said it needed to be cut off above the knee or she would die. She said I had a full life and am fine with death. She died 3 weeks later later of gangrene. If a hospital ever said that to me again I would say I don't care what your policy is. Honor her directive or transfer her to a hospital that will and I will be on the sidewalk explaining your policy to the evening news. Just because you have medical directives does not mean hospitals will follow it.
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@Bob
My family went through a similar experience with my father. He had a very comprehensive and attorney created DNR document provided to the hospital. He had made his wishes know to family. But, my brother was not on board as he was not ready to let his father go emotionally. The hospital did not honor my Dad's DNR. When I questioned hospital leadership, they told me "dead people don't sue". It's so important to get family on board well ahead of time.
21
Surgeons don’t want their “mortality statistics” to increase, so they resuscitate people during the operation and after the operation. We need surgeons who cherish people, not statistics.
19
This weekend my hospital rounds will cover about 25 patients. The majority of them will be over 80 years old. Instead of one problem them will have 4 or 5 serious diseases (congestive heart failure, advanced stage chronic kidney disease, cancer, dementia, frailty). If we, as doctors, do everything we can then many of them will survive to leave the hospital. Where do they go? Nursing homes, that are now politely called Transitional Care Units.
When my own father was in his nineties I got a frantic call from his cardiologist who wanted to do an emergency coronary angiogram and place a pacemaker/defibrillator. My response: Absolutely not! There was stunned silence and they the doctor told me he would be at risk of sudden cardiac death if they didn't proceed. My response: What is wrong with sudden death if you are 94 years old? Would you prefer a long, lingering death? He was discharged and some time later died at home, in his own bed.
Everyone of us is born, grows old (if we are lucky), gets sick and dies. 100%. Tormenting the elderly in the hospital with aggressive interventions is not only futile and irrational, it is cruel.
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@Jon Tolins
Its also another way the elderly is relieved of their $$.
41
@Jon Tolins I don't dispute a thing you stated in your comment, Doc, and would have also refused the defibrillator for my nonagenarian parent. But what is one to do if an elderly loved one is having a heart attack before your very eyes? Just watch? I'm not sure what paramedics or family members should do in these situations.
6
@RJ DNR/DNI and medical directive is what is followed in that situation. Figure out how you want to end your life.
9
For the POLST/MOLST to be truly effective, it must be displayed or available at all times, 24/7. In the home, it is usually printed on magenta paper and is posted where it can be seen easily. Many states no longer use wrist bands for 'No CPR'.
Key to preventing many, but not all, unwanted CPR efforts is for the patient's family and network of physicians to fully understand the patient's wishes. This means open discussion. Now that many primary physicians no longer provide hospital care, there is a special burden on the PCP: If a patient is hospitalized, and if the medical team seems to be pushing for care the patient really did not want, the PCP should intervene to promote the patient's wishes. I have stopped unwanted care in the ER and in the ICU where I have had clear knowledge of the patient's wishes.
This is a "wake-up call" issue for the electronic medical records industry. We can't flag records now for what I have called "significant medical issues.:" We need to have a pop-up window when a patient hits the ER (now increasingly even when the EMT's are dispatched) to notify everyone of the patient's wishes, and that there is a PCP or relative who can be called to verify the instructions.
68
@Jeff - One problem we found with my mom was that her PCP is one whose practice contracted with a Hospitalist. I believe my 95 year old mom's PCP would have honored her wishes, but somehow that was never conveyed to the Hospitalist.
1
I have learned this the hard way - in Oakland County MI - if 911 is called, and the person is non-responsive, the EMTs must continue CPR until a person shows them a copy of their medical power of attorney and tells them to cease, or until they are working on a cold body. If the death occurs outside a hospital the police must be called, come to the location, inspect the scene, and make a report.
24
@Bonnie Luternow - When my neighbor's 50 year old son died suddenly in his sleep, there were 8 police cars sent, as well as an ambulance and fire truck. The latter two left after a short time but the last police car didn't leave for 8 hours. I believe they turned the house upside down looking for something that could have been a cause of death, and I know they went through his vehicle with a fine tooth comb for over an hour.
3
When my mother passed in October she put a DNR on herself. The nurse explained to us that cardiac arrest is very traumatic and she would be on life support if one happened. She was clear, no tubes, no support. Things unexpectedly turned worse and we took her off the support she had and she passed. She always said she wanted to go quickly.
Every day we would pass people on respirators and kept “alive” because no one wanted to face the fact that life ends.
The staff said they had never seen anyone as organized as my mom.
Be clear about your wishes.
155
Useful article.
This is something almost all physicians know but more of the public needs to learn.
The medical and technological advances of the last half century have appeared to some to make death an optional occurrence. And while it is true we are able to prolong life in many patients, what many family members are asking of their clinicians is more akin to a cure for death. Alas, this is solely the realm of the divine.
Our current society has, simply put, forgotten how to die. This used to be a family affair in one’s home surrounded by loved ones. A belief in the life to come would ease fears all around. The occasion to celebrate the sick person’s life would reunite those who may have been estranged.
Too many die in ICUs on ventilators with tubes sticking out of every orifice. There is certainly a knowledge gap between people in medicine and those outside regarding the success of these aggressive interventions. That being said not enough families ask me what I would do if this is my loved one. Rather, too many try to weaken God by claiming that He will work a miracle, but only as long as the patient is on life support.
We definitely need to talk more honestly about death in our society and among our family members.
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@Andy - Well explained. I also think that sometimes, perhaps often, when a family member's loved one is suddenly unresponsive, the default response is to call 911, without understanding that if you do that, your loved one is going to be subjected to aggressive measures that the patient might not have wanted. Even family members who agreed with the patient's "no aggressive treatment" request can be frightened into calling 911 without understanding what would happen after that.
Nursing homes are also very quick to call 911, and will often do so even when there's a DNR. Family members have to repeatedly emphasize the patient's wishes to stop the nursing home from calling 911.
50
@MegWright One reason nursing homes are quick to call 911 is perceptions about the likelihood of a "negligent care" lawsuit. All it takes is one relative and a lawyer ...
25
@Andy
In my mom's passing the doctor and nurses were very good, but we were also well-prepared and honest. the doctor asked us what we wanted. We were clear. Mom's stellar days were behind her, her great days were behind her, her good days were behind her. She might have some more OK days in front of her, and if there were medical treatments that could help her have those, they could do such treatments. UNDER NO CIRCUMSTANCES did we want anything done that would build up a stock of bad or terrible days. From articles like this, we knew that intubation and revival from cardiac arrest were not going to give her more OK days.
And so, after a hospital stay of five days, she passed away. The doctor was grateful we knew about how poor the outcomes of ICU would be for her, and that we knew about ICU psychosis. All of us--her, our family, and her caregivers were on the same page and knew we had made decisions based on sound knowledge. She is gone and I mourn--but her passing went as well as any passing could for her--and for us and her caregivers.
29
78 and I don't know what might be best for me. My lovely day, in a power chair, dinner with friends, a roll around the pond noting new flowers, missing birds, check that my vote by mail request is in, might not sound like much to others but it's my life as I learn to enjoy it now. Hard to say "please don't even try to get my ablated heart clicking again. "
102
It sounds like you very much want attempted resuscitation in the event of an emergency, so please make your wishes very clear to loved ones and health care providers. I hope you continue to live a very happy life. Your life sounds wonderful.
33
@joan Yes Joan but at 78 (even at any age) you will have deficits after your heart stops and is then "restarted". We all look to the "miracle" cases the 1% who have had an MI and recover w/o any deficits thinking "well me too". But you are more likely to end up in an ICU, on a ventilator and on medications to support your blood pressure and heart rate, with chemical nutrition pumped into your veins, being turned every few hours to avoid skin breakdown because you are unconscious on paralitics and likely in restraints waiting for a family member to beg for you to be taken off life support and feeling terribly guilty about making that decision.
19
@joan And it sounds like you have the funds to still have a meaningful life - most don't. They are not traveling around ponds, they are rotting in NH.
11
Last year my 92-year-old father died at home. I had been his live-in caregiver for seven years. He was frail and had congestive heart failure and moderate dementia with significant aphasia.
I found him unresponsive on the toilet. Five minutes had probably passed since I helped him into the bathroom. I called 911. I was told by the operator to pull him off the toilet and start CPR. I used all my might to get him on the floor.
The paramedics got there just as I was going to start CPR. One of the paramedics took me into the kitchen. It was then that I noticed the POLST on the refrigerator. My father had filled out a POLST indicating DNR and I'd totally forgotten about it! This was so unlike me. I had called 911 before a couple of times. I made sure the paramedics got the POLST. I informed the ER staff the minute I got there that he had a POLST. I carried a copy in my bag at all times! Forgetting he had a POLST was something I never would have anticipated. I guess I was so focused on helping him. Thankfully, the paramedic asked me if I wanted to honor the POLST and I said yes. He told the other paramedics to stop CPR.
Looking back, I was never told what to do if I found him unresponsive in the home. Was I supposed to call 911 and tell them about the POLST on the phone? Thank God, they honored the POLST and stopped CPR. I would have felt awful if they had managed to resuscitate him, whereby depriving him of a better death.
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@Mel Your story is very important to tell. In the heat of the moment of finding a loved one down, we've been trained to call 911. Every CPR class teaches that as the first thing you do. But in this case, as you've stated, that's going to produce the wrong outcome often. When a person whose wishes are known, and like here are documented with a POLST, calling 911 is what is usually done, but as you did handing the paramedics the DNR order the moment they walk in is important. Not doing what a person has stated that they don't want done in their final minutes is paramount here.
30
How traumatic for you. I’m so sorry. You sound like a wonderful person.
11
I was under the assumption Hospice patients were DNR. I know my wife and my father were while in hospice!
I have been thinking about getting a DNR for myself, as age brings on more and more health problems! I believe my children will be better off for it.
30
Not necessarily. As a medical director for a hospice, we are trying in the end of life community to open the door to hospice for more and more patients who have preconceived notions that hospice only is for the last 2-3 days of life. As such, sometimes when a patient with a clearly terminal illness is referred to us, they (and/or their family) are not completely ready to sign a DNR. Sometimes it takes days/weeks or even months of physical and cognitive decline for families to understand and discussions with myself and our social workers and chaplains to execute a DNR. Unfortunately, sometimes the patient declines more rapidly and their family decides to revoke hospice and pursue an aggressive route.
19
@Tim
This is why the discussion and the plan need to happen well in adance. As my doctor said when I asked whether I was too young (78) and healthy for a MOLST and DNR, "I don't think anyone is too young and healthy for a MOLST and DNR"
18
@Tim In my experience with both parents in hospice, at different times, is that if you call 911, they are no longer in hospice care, at least in California. Hospice is for the dying. Once you making the decision to resuscitate, the intention is to not let the patient die. If the patient survives, the hospice process, including evaluation, starts all over again. Sometimes patients are in hospice because that's the only way they can return to an assisted living facility after hospitalization. If they improve, they are removed from hospice. If not, they continue.
9
The key phrase in this thought-provoking article is that “the family member called 911.” It’s what we’re all conditioned to do, right? That call activates an EMS network where each layer of response is under general medical orders to get the patient to definitive medical treatment. As an EMT that was my training. My state’s laws required us to look for a DNR bracelet attached to the patient, but if anything looked incorrect about the details on the bracelet, we were trained to cut it off and proceed with resuscitation measures. Vital signs, history if available, and get them to the next level of care. Decisions on CPR were not our call unless there were “obvious signs of morbidity” (use your imagination). ON THE OTHER HAND: if EMS is not activated, none of this happens. It’s an agonizing process to watch resuscitation being performed on someone whose condition makes it inappropriate, but the dynamics of EMS and the conditioned response to call 911 is hard to resist. Conversations between patients’ physicians and their family about when to call and whom to call would help change this dynamic.
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A key point in this article and the reader comments that follow is the necessity for families to have these discussions about how each one wishes to face their deaths and how to formally and legally ensure those wishes are followed. I appreciate the comments that include what really happens to a person’s body when CPR is performed on a fragile patient.
When my 98-year-old mother broke her hip at home we knew she was going to die because she had congestive heart failure and failing kidneys. We called 911 because she was in such pain. By the time we arrived at the hospital she was prepped for surgery. When she revived she was fortunately still very clear mentally and had lost non of her mental acuity (which often happens in the elderly who are administered anesthesia). The hospitalist was ordering post-op physical therapy when my mother began pleading with nurses to call hospice. It was her kidney doctor (who we called) who finally had to intervene with the doctor in charge to convince them she was dying and no medical intervention would save her to get that call to hospice made for her. She had her last week in palliative care at home as she wished. My husband and I have DNRs and our own addendum explaining when and why we don’t want special measures made to save us so that our children don’t have to argue for us. Copies are with every doctor we see, in our glove compartments and with our children and by the front door. Do it now no matter how old you are!
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If I were an EMT or a physician or a concerned bystander, I would not want to play God. In the absence of history with a heart attack or stroke victim, I would err on the side of saving a life no matter the age. To do nothing is also doing harm.
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You say you don’t want to play god, so your default is to start resuscitation. Consider that by starting CPR, you are playing god. Perhaps the cardiac arrest is God’s will, and by working to reverse it, you are thwarting God.
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@R. Anderson “I would err on the side of saving a life no matter the age.”
What kind of “life” are you saving them for?
Heart attacks and strokes aren't the only maladies torturing our bodies. Without knowing the situation, calling 911 is imperative, yes. But friends and relatives must absolutely have those difficult what-if conversations. They must also respect the individual's personal choice and understand that frail bodies and brittle bones can't withstand the physical violence that's occasionally required for successful resuscitation.
For many, “life” is day after endless day of misery, pain, and loss. Be sure you're not adding to it with that well-intentioned call to 911.
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@Wagner Schorr-Ratzlaff : There is no god, so get your POLST form in order and have it prominently displayed!
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The whole point of hospice is to accept that death is coming soon and caregivers want that death to be as peaceful as possible. How sad that the wishes of the cancer patient in the opening story were not followed.
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Some people want to eke out every second of life - no matter how grim - and that is their right. But others do not. And that should be THEIR right.
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My family member was among the 2%, although the hospital stay was rocky when they experienced hallucinations in the stepdown unit. Paramedics and ER physicians are reluctant to accept DNR’s. It took some persuasion to get the geriatrician to agree to a POLST, which was never used.
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Cardiac arrest! The doctors withhold CPR. Death ensues. Family arrives.
Doctor: We decided to not attempt CPR.
Family: But he wanted it, if necessary. So did we.
To paraphrase Dr. Kei Ouchi: This is not going to have a good outcome.
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@rifis I was a Fire department EMT for 25 years and encountered theses scenarios repeatedly. Family members would find their loved ones and call 911. Once we responded we had no choice legally, absent a written DNR, but to initiate CPR. If you don't want, or your elder family member didn't want CPR, then please don't call 911.
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@Steve 911011
Hubs and I are elderly with various medical conditions. We have a pact: "Don't call 911".
We also have our MOLSTs prominently displayed on our refrigerator. We each carry a copy of our MOLST in our wallets. We also each wear a medical medallion that gives our name and says "DNR, MOLST in wallet." We printed the copies in the same bright pink as the originals.
You can buy the medallions from online retailers. When you choose the medallion, a dialog box appears for writing your message.
It's also necessary, as the article says, to discuss this issue with family and close friends, and all your doctors, so that everyone concerned knows your wishes.
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If there is no DNR, what happens to the love one who finds their elderly relative collapsed on the floor, and does nothing? Aren't they at risk for criminal charges for negligence?
If some heart attacks can be treated with CPR and defillibration and some cannot, then the right answer is to develop techniques so that MDs and EMTs can tell the difference, and modify the law so that MDs and EMTs are not required to do ineffective CPR.
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The problem is that everyone hopes their family member or patient will be in that 2-3 percent. And 2-3 percent of them will guess right. It's like a slot machine, just enough winners to keep people playing a losing game.
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@Di - I think the more common scenario is that a family member finds the loved one unresponsive and panics. We've been trained since childhood to call 911 in an emergency, and an unresponsive patient certainly looks like an emergency to the untrained family member who's with him. Families need to understand that if the patient has a DNR, calling EMTs is the wrong thing to do.
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@MegWright
Also who wants to be the family member who did not take action? I think that I would likely feel guilty and that I had killed grandma or someone else if I did not call 911. That would be a hard decision to live with.
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@FerCry'nTears it is actually worse to be the one who prolongs the suffering that is realized after the fact.
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