COMMENTARY

No One Here Gets Out Alive: DNR Code Status

Melissa Walton-Shirley, MD

Disclosures

May 22, 2019

In the immortal words of rock legend Jim Morrison, "No one here gets out alive." But more and more patients want some say in how they will leave. Historically, the healthcare profession has been slow to embrace this.  Although resuscitation was first documented in the early 1700s, formal do-not-resuscitate (DNR) orders were not written until the 1970s. Since that time we have validated this choice for millions of patients, but we struggle with how best to consider the triangular concerns in the dying process: The patient's preference, the provider's knowledge of clinical appropriateness, and the family members' opinions. All must be factored into the care of those who are dying. 

The Sculptor Who Shook Me Out of My Comfort Zone

I've coexisted peacefully with my patients resuscitate/do-not-resuscitate options for 30 years. My belief is that a death that comes too early is a tragedy, too late a misery, and I have no doubt that an inevitable death orchestrated well is a blessing.   A recent incident, however, shook me from my comfort zone.

A 73-year-old man was admitted for new-onset atrial fibrillation and chest pain. After formal introductions and an exam, we had a competent two-sided conversation about his diagnosis and plan.  He asked appropriate questions regarding anticoagulation, rate  vs rhythm control,  echocardiography, and risk stratification. While I was taking a social history, he directed me to Google him. It revealed his staggering body of work as a sculptor. He derived much satisfaction from my amazement as I briefly swiped through his work. While populating the electronic health record, I was shocked to see that he had a DNR status—in fact I was so shocked that I went back to his room for a discussion.

"I note that you have requested no resuscitation.  Is that correct?"

 "Hmm, what exactly does that mean?" he replied.  

"Well, if your heart were to stop beating or you were to stop breathing, we would allow you to die peacefully without any efforts to bring you back but would provide comfort meds of course. Otherwise we would give meds to attempt to restore a heartbeat, perform chest compressions, possibly perform electric shock, and likely introduce a breathing tube." 

He hesitated a moment, contemplating the potential scenario, and said, "You know, no one ever talked to me about that."    

I then pointed to the bright purple DNR band on his left wrist that I hadn't noticed previously, given his zest for life and continued productivity. I've learned as a locums cardiologist that the color for DNR bands has not been formally standardized. One study revealed that eight different colors were used to signify a DNR status across multiple facilities.[1]  

Just to make certain, I redirected the question to him.

"Does that mean that you do wish for us to make efforts to bring you back  if you experience a life-threatening event?"

"Yes, it does," he said without hesitation.

I immediately changed his status to full code in the electronic health record and notified his attending physician of the change.  I also borrowed some scissors and snipped the bracelet off his wrist  because it was too important to delegate. We proceeded with his workup without incident, and he was discharged home to sculpt again.

The DNR Wrist Band

But that wasn't the only incident.

One month later, a relative who is a nurse visited her elderly father in the hospital. He lives alone, drives, and takes care of his own finances. Upon entering his room, she was shocked to see that he was wearing a DNR band. 

"Dad, do you know what that band means?"

She said her father held up his arms and looked at both wrists covered with several bracelets and two IV's and said, "I have no idea. They just put all of this stuff on me at the same time." 

"Well, do you want to be a DNR? Do you want us to just let you go if you have an emergency here in the hospital?"

"I came here to get better," he said emphatically, rather shocked.

With that, she went directly to the nurse and rescinded the DNR order.  He underwent a pacemaker implant, was discharged home, and was soon back to usual activities. 

Laws on the Books

There is certainly an argument that a lot more patients should be DNR, but the lack of time for meaningful conversation is now adversely affecting competent patients in their decision-making. 

Since the early 1990s, there have been legislative efforts to standardize end-of-life measures.  The Patient Self Determination Act of 1990  brought the patient front and center in the decision-making process for advanced directives. As a result, the rate of DNR orders increased from 31% in 1990 to 52% in 1993.[2]  In some states, other legislation has muddled the process, as happened with the passage of the Texas Advance Directives Act of 1999, sometimes called the "Futile Care Law,"  which gave hospitals the authority to remove life-sustaining care against a loved ones' wishes. 

That legislation is pitted against the more recent Texas Senate Reform Bill 11, which defines who can authorize a DNR. This law became effective in April 2018 and states that family members and patients must be informed that the patient is coded DNR; it especially empowers parents to direct the DNR status of terminally ill children. To counter the 1999 legislation, doctors are directed to revoke a DNR if so requested by the patient, or a family member if the patient is incapacitated.[3]       

Beyond legislation, nothing beats preparation, conversation, and consideration. We could do with a complete overhaul of our approach to DNR code status in the United States. Here are a few considerations:

  • Place as much emphasis on explaining code status as we do on things like diabetes education or preprocedural consent.

  • Apply a "time-out" for each patient who enters the system in the same manner that a flight attendant directs passengers to give their full and undivided attention to the emergency instructions.

  • Make certain the competent patient understands and signs a consent for a DNR status.

  • If family members are present during this conversation, ask them to co-sign the DNR document.

  • Allow providers to use a phone conversation or a FaceTime option with a witness to affirm or deny DNR status (we have the technology; let's use it), then enter that conversation into the record.

  • Refrain from assuming we understand the patient's desire by asking vague questions such as, "Do you have an advanced directive or living will?" A living will often addresses a desire to avoid intubation or resuscitation in the event of a terminal illness but does not usually cover acute changes in status that are reversible with a short period of mechanical ventilation, for instance.

  • Physicians and nurses should question and provide further education when the DNR decision doesn't make sense clinically.

  • Be aware that patients and significant others often don't understand phrases such as "code status," "DNR," or "DNI" (do not intubate).

  • Standardize DNR band colors.

  • Replace the term "DNR" with "CMO" (comfort measures only). DNR implies a sterile hands-off approach, whereas "comfort" may provide some measure of confidence that patients will die with dignity and as little pain as possible.

  • Drive a national campaign that educates the public regarding end-of-life options.

Until physicians aggressively fight to take back time with patients in the office and at the bedside, we should question every "decision" that seems inappropriate. Jim Morrison was exactly right that none of us here will get out alive, but as many patients as possible should get a say in how they make their exit—and we won't know that until we take the time to ask. 

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