One of the big end-of-life care issues is the DNR/DNI or “do not resuscitate/do not intubate” controversy. This issue comes up, because normally in an emergency life-threatening situation, the medical professionals who deal with the patient, from paramedics to nurses and doctors, are trained to do everything they can to revive the patient. This goal of preserving life is part of the medical oath, which is taught in medical school and reinforced again and again in everything medical professionals do in dealing with patients – “do no harm and do everything you can to heal the patient.”
For example, in an emergency situation, such as when a patient has been in a car accident or has nearly drowned, so that their heart rhythm or breathing becomes severely irregular or stops and their blood pressure or their pulse drops dramatically, the patient is normally placed in a Code 99 status. In the hospital, this situation usually leads to someone pressing a button on the wall to trigger an emergency response from all available medical personal. Within minutes, the patient’s room fills up with 15 to 20 people, and a medical team begins cardiopulmonary resuscitation to restart the patient’s heart and breathing.
The basic process involves checking the patient’s airway to see if it is open, determining if the patient is still breathing or trying to breathe, and examining the patient’s circulation to determine if he or she still has a pulse and blood pressure. After that, since the team has only a few minutes to revive the patient’s breathing and circulation, the team members quickly organize themselves based on their predetermined roles, such as to lead the team or handle a particular function, such as monitoring the machines, providing CPR, launching compression, or providing medications by injection to an unconscious patient.
To carry out these tasks, the team members may ask a series of questions, such as is the patient breathing or does the patient have a pulse. To deal with the urgency of the situation, the doctor in charge of the medical team organizes who does what. Then, the trained team self-organizes to create a coordinated effort in which everyone knows what to do to restore breathing and circulation. Each person has a clear knowledge of what actions to take to help the patient survive.
A key consideration is the way different bodily processes can affect each other. A good example is the way the lack of circulation of the blood when the heart stops can have the most deleterious effects most quickly, since after 3 minutes, a lack of blood to the brain can result in irreversible brain damage that shuts off other bodily functions. By contrast, a person can go without breathing for up to 3 to 4 minutes without irreversible damage. However, in practice the two systems affect each other. For example, if a patient’s circulation stops, within seconds his or her breathing will shut down, and the medical team will simultaneously attend to both systems at the same time. The process is like having to deal with a bonfire that has gone out of control, so everything is erupting in flames at once. In response, highly standardized protocols are used to deal with the evolving situation.
Certainly there are cases where a problem in breathing occurs due to congestion in an airway, such as when a person choking on food has a cardiac arrest, or when a heart attack leads to difficulty in breathing,. In such cases, a doctor or another person have to act quickly to resolve the initial problem, such as dislodging the food from a person’s airway or massaging the person’s heart through a cardiopulmonary resuscitation. The goal is to seek to revive the patient’s circulation and blood pressure in order to revive the patient and return him or her to an earlier or baseline status. But generally the heroic action of one person is the exception in most emergencies, since a full team effort is needed to revive the patient.
Whatever the situation, if a medical team is successful in this everyday emergency, the patient can be revived successfully and after a period of healing return to his or her everyday activities. Even so, the potential for saving the person can be quite low he or she has had a true cardiac arrest, since the mortality rate is about 90% not matter what anyone does.
However, this recovery after an emergency is quite different from the experience of the end-of-life patient who has many medical problems which lead to a sudden heart stoppage or the cessation of breathing. In this case, it is generally not a good idea to apply any emergency treatments to save the patient, because these will make his or her condition even worse than it already is, such as by breaking the ribs during a resuscitation procedure, leading to continuing pain and suffering. That’s the reason for the DNR/DNI option, whereby the patient can opt not to receive any emergency treatment to restart the heart or breathing, because the patient will only experience more pain and suffering if the revival is successful. Then, once this DNR/DNI option is exercised, the medical team will not do anything, so the patient can die naturally in peace within a few minutes, which is usually the result when the heart and breathing stop.
Dr. Sebastian Sepulveda has had nearly 30 years’ experience as a doctor and professor of medicine, working with patients in a community hospital and personally caring for them, many times as the sole provider of end-of-life care. Since 2005, he has been in private practice, dealing with private outpatients and with inpatients in hospitals, especially with those who have what appears to be a terminal condition. His book At Death’s Door and Death’s Door TV series pilot based on his work will be released in 2017. His website is at www.atdeathsdoorbookandfilm.com.