To Resuscitate or Not ?
“Life is the most important gift we have. To be able to wake up in the morning and watch the sunrise is one of those blessings whose importance we’ll never really know. On our journey, we meet so many people including our family and friends; we get used to the idea of living in groups, we get used to living with other people, their habits and their presence- till one day, someone departs never to return again. And then we wish we could turn time around, or do everything we could to bring that person back,
…but time is not always on our side.”
In resuscitation too, time is everything. Medical science has seen the development of many theories over the years. Some of these concepts have been implemented into medical procedures and form the basis of science as we know it today.
One very arguable concept is the DNR or Do not resuscitate ( alternately called No code or End-of-life). This is a written order / form attested by the doctor which states that in the event of the patient’s heart stopping, no cardiopulmonary resuscitation (CPR) or any other form of revival is to be carried out.
This is to carry out the patient’s wishes or his medical power of attorney to allow natural death (AND).
The DNR however, is only with regard to reviving the heart. Other procedures and drugs for pain alleviation etc. are unaffected when this clause is in effect.
Isn’t resuscitation but natural?
Ever since the late 1900s, resuscitation was the natural answer for medics to revive unresponsive children and adults. CPR was immediately offered to sustain life and blood flow to vital organs while efforts would be carried out to determine the cause of the arrest.
The basis of DNR is that CPR is more of an attempt at saving life rather than a guarantee. Some survivors have had to live with a terrible quality of life post CPR including brain damage and surviving in a vegetative state.
Some situations where DNR is a good option is if –
- Death is imminent ( such as a terminal illness)
- CPR may not increase survival chances
- CPR may cause more harm than good i.e. patient survives but in a practically degenerative state
Who decides the DNR ?
Ideally, a DNR is expressed by the patient himself in cases where the scenario is inevitable or pre-determined in cases like a terminal illness.
It should be stressed that, in the United States, an advance directive or living will is not sufficient to ensure a patient is treated under the DNR protocol, even if it is his wish, as neither an advance directive nor a living will is a legally binding document.
When the patient is not in a state to make a conscious decision in this situation, the next of kin have the authority to make this decision. For instance:
- Parents of patient
- Children of patient (adults)
- Legal guardian (power of attorney)
- Siblings of patient (adult)
Why is it important to consider the quality of life?
Research shows that survival rates for out-of-hospital CPR in adults has a pretty low survival rate ranging from 8- 30% , depending on the age of the patient, cardiac history, cause of arrest etc. In kids the survival rate is significantly higher at about 35%.
Quality of life is important in deciding DNR because several patients after successful CPR suffer hypoxic brain damage, sometimes resulting in irreversible brain damage.
What is your take on DNR ?
Consider the case of 72 year old patient Eric. Eric had a cardiac arrest on Monday at 11:15 and received CPR about 7 minutes after arrest. While his heart was revived, Eric never regained consciousness and stayed comatose even a week after the accident. Advanced sepsis had triggered the attack, causing multiple problems.
After hospitalization too, Eric suffered multiple cardiac arrests, each time revived using chest compression and open chest massage. The doctors believed Eric would never regain consciousness and if acute medical care was given, the maximum he would live with, would be in a vegetative state.
Eric’s family was then asked to decide if DNR was the best option for Eric considering the prognosis and imminent fatal nature of Eric’s health.
The family decided to keep Eric on ventilated support against advice on DNR by doctors.
Two days later, Eric’s heart stopped and could not be revived again.
Food for thought –
Do you think choosing DNR was a better option for Eric’s family? What is your take on DNR and what cases do you think DNR can be opted for?