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Occasional ramblings by an anesthesiologist/mother (and sometimes her husband).

Saturday, October 07, 2006

A note on Code Status

Back in June, I linked to Fat Doctor's post on advanced directives and why it is so important to have one. Feel free to click here and re-read her say on the topic.

I feel the need to expand on one section of that topic, because working in the ICU it is something that often comes up. The "code status" of a person.

First a brief history on codes and CPR. This info is taken from The ICU Book by Paul Marino (a must have for any resident working in an ICU rotation). In 1960 JAMA published an article titled "Closed-Chest Cardiac Massage." It was based on 5 (yes 5) case reports about acute cardiopulmonary arrest. It concluded that cardiac massage was proven to be effective. This was the birth of CPR. In 1993 the Journal of the American Board of Family Practice did a 30 year review of in-hospital CPR. Of the 19,955 patients in the study 15% survived.

After the resuscitation there is the possibility of multi-organ damage and the potential for poor neurologic recovery. The longer the arrest time/duration of CPR the greater the risk of permanent neurologic impairment.

Codes are not like what you see on the medical shows. They do not work most of the time. When the do work, it is rare that the person is completely as they were before the code.

When you discuss your "code status" in your advance directive terminology comes in. DNR means do not resuscitate - no drugs, no chest compressions, no shocks etc. DNI means do not intubate - no breathing tube, no machine breathing for you. You can be DNR but not DNI, a DNR/DNI, or DNI but not DNR.

To be DNR/DNI is simple. It is clearly spelled out what you, the patient, wants done.

DNR but not DNI isn't a real problem either. There are situations where intubation for a short time will allow support while treatment of the underlying problem (acute heart failure, pneumonia, etc) can occur.

From a treatment perspective, it is the last one DNI but not DNR that poses a severe problem. We can do every part of the resuscitation process except put in a breathing tube. In order to perform CPR/recuscitate a person the first step is securing the airway, i.e. intubation. No amount of chest compressions to move the blood through the body will do any good if the blood has no oxygen to carry. Even if a person is young enough to get a blood pressure and pulse back, their brain has been deprived of oxygen.

In my mind this is doing a patient harm. I in good conscience could not fill out the paperwork to make a patient DNI but not DNR. And to be honest, I view my colleagues who do so with much less respect as physicians.

Keep this in mind when you're making decisions for yourself, and if forced to for your families. It's a harsh reality, but one that needs to be faced.


Anonymous Dr. Decaf said...

I don't find DNR or DNI all that useful. I am (as a primary care internist) often faced with a very debilitated, very elderly patient who has had a massive insult like a large stroke or a big pneumonia who is unlikely to live independently or perhaps even dress themself again who needs a lot of supportive care if we are going to try to keep them alive. The decision we have to make is would this person want antibiotics, IV fluids and 2 weeks in the hospital followed by 2 months or more of rehab or would they like to be made comfortable and allowed to pass?

Sometimes you can't predict what kind of result the person might get, but often you can get a general idea, will need lots of rehab, but should return to his baseline status or will need to live in a nursing home for the rest of his life, but may be able to do some of his own self cares and will likely be able to recognize family members. You just do the best you can in the prediction department.

It always seems a tragedy to me to put some one through all the invasiveness of modern hospital care: the lines, the instrumentation, the turning, the suctioning, the blood draws and then to hear their family say, "Mom would never have wanted to live like this" six months later when it is too late to do anything about it.

Sometimes at routine office visits, I ask my patients this question--for what kind of outcome would you want to be supported or more simply what makes your life worth living and they give me surprising answers. One retired physician told me that if I thought he would have to be discharged to a nursing home even if I thought he would fully recover, he wanted no support of any sort. A retired WWII fighter pilot told me that if I thought he would ever be able to feed himself again even from a nursing home bed he could not get out of, he wanted me to do everything I could think of for him. Another answer was if I will be able to talk with my grandchildren, I want to suffer through whatever you think might make that more likely.

When families know what their loved ones want from life explicitly, it helps them make the decision to treat pneumonia with medications for breathlessness or agitation, not antibiotics, or to provide the aggressive care that modern medicine has for people who want it.

It is a funny thing to view "what makes your life worth living?" as a practical question, but it is.

10:13 PM  

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