In Part One of our series, we all accepted the inevitable and subsequently gave serious thought to who we would choose to make decisions for us were we unable to do so. Nah. I know we’re all still in denial. That’s why I plan to keep nagging you all by talking about this with some frequency. Today we will talk a bit about some of the actual decisions you need to make for yourself, and possibly for a loved one. Because I would like to not overwhelm you with information and give you enough information, I will break this down a couple of issues at a time. Today we will discuss the two biggies: Do Not Resuscitate orders and artificial nutrition.
DNR stands for ‘Do Not Resuscitate’. What this means is that if your heart stops beating and you stop breathing, your medical and nursing providers will not attempt CPR or any other means of restarting your heart or breathing. When making this decision it is important to be realistic about the limits and success of CPR. TV representations of CPR are very unrealistic, with survival rates over double that of real life. Also, contrary to what you may see on TV, people don’t get up and walk around after being resuscitated. They spend days, maybe weeks, in an Intensive Care Unit on ventilation and, if they survive long enough to be discharged, a rate that has been described as being close to zero, there is often residual physical and cognitive damage and months of rehabilitation that follows.
CPR survival rates range wildly and are affected by how sick you were in the first place. Generally speaking, 3-37% of people outside of a hospital who get CPR survive the initial resuscitation. It’s 3-15% for in hospital attempts, reflecting the poor outcomes for people who are already sick or elderly. Again, this is ‘survival’ of the resuscitation attempt only. As an historical side note, it has been noted that CPR survival rates have gone down since its introduction because it is used so often on people who are not appropriate candidates (people too sick or of an advanced age to survive)
The best candidates for CPR are younger, generally healthy, victims of trauma or who have a sudden cardiac arrest caused by an arrhythmia.
If you are making this decision for an elderly family member, the simple, honest truth is that they will not survive the attempt. And even if they do, they will never get out of the ICU. That is the blunt and honest truth. Even more ‘Dr. House’: we will do nothing but crack their ribs into pieces and disrespect their death by attempting it.
DNI: Do not intubate. This generally goes along with a DNR. I have seem some orders that are DNI only which is utterly nonsensical as you will need to be intubated if you stop breathing and your heart stops. Why do CPR with all its intendant risks if you’re not going to follow it up with respiratory support?
Artificial Nutrition: Artificial nutrition most often takes the form of tube feedings. This is a tube that is surgically inserted into your stomach or intestine and a liquid supplement is infused directly in. There are several indications for this, and it is not necessarily an end of life procedure. For example, Roger Ebert has a gastric tube as a result of his cancer and surgery. Anyone who loses their ability to swallow is a candidate. People with esophageal or gastric cancer or people who have neurological swallowing issues because of a stroke are just a couple of examples. Most of these people live perfectly fine lives with a feeding tube. However, if you are in a persistent vegetative state or end stage dementia or end stage neurological disease, it is a different kind of decision. You will have to think about how you would feel having this is there was no hope of recovery or returning to your previous mental state. Many people with dementia lose their appetite as well as the ability to coordinate their chewing and swallowing which puts them at risk for aspiration and pneumonia. A feeding tube is often recommended in this situation. A feeding tube will only provide nutrition. It will not cure or reverse the natural processes that are occurring. The same is true of IV hydration. As people lose the ability to swallow, they become dehydrated and the kidneys and body shuts down. Fluids may be administered, but will only delay the inevitable.
It is important to note that it is not ‘starving’ someone if artificial nutrition or hydration is declined. Any pain at end of life would be managed aggressively and comfort and dignity are the paramount goals. In addition, the dehydration that naturally occurs results in electrolyte imbalances that cloud pain and cognition and provide a natural pain killer and release of endorphins.
I think that’s enough for today, kids. If you want some help thinking about these decisions, there is an excellent resource called 5 Wishes that helps you think through these end of life decisions. In the next installment, I will discuss dialysis, Do Not Hospitalize orders and organ donation – and the exciting unveiling of my own advance directives – Spoiler Alert! – Don’t keep me alive.
