DNR/DNI

It's been a long time since I've last posted! I've quickly come to realize that being an intern is FAR more time consuming than it was to be a medical student!

I've finished nights, worked a few shifts in the ED, and now back on the wards. I definitely love the wards the most!

I'd like to touch on a topic we discussed in conference today- the issue of DNR/DNI. For those that may not know, this is the "Do NOT resucitate/ Do NOT intubate". When a patient is admitted into the hospital, as housestaff (and I can only say this for medicine, since i'm with the Dept of Medicine), at the end of our progress notes, we put down code status. This should be in our admission notes and our daily progress notes. This is done so that we know, as well as cross covering doctors know, the patient's wishes. That being said, it is definitely not an easy task to do. Of course, if I have a younger than 50 year old patient, I automatically assume that the patient is full code. This is definitely not the right way to approach this, but for the most part, a young, healthy individual should NOT want to be DNR/DNI, otherwise, I would probably get a psych consult.

But for our older patients (and of course as the population ages and we see more in the hospital), it is not such an easy task. For some patients, it's clear that they should be DNR/DNI. Their quality of life would be so significantly impaired if they were to code and survive, although most likely, these very sick patients wouldn't survive. But for others patient's it's not so clear. And even in those that we think are "clear", we as physicians don't decide, it is left up to the patient.

So the question now is, what is the right way to approach a patient about their code status? You would hope that for older patients, especially those with multiple medical problems or end stage diseases, this topic should be brought up well in advance to a hospital admission, preferably in the ambulatory care setting, but unfortunately, this isn't always the case. I have now walked in to quite a few patient's rooms on admission, and when I asked them if anyone has ever talked about their code status, they say, "no". This puts me in a bind. This person has never met me, and here comes this young doctor asking if they want hospital staff to do "everything they can" to keep them alive. Often, patient's are not even quite sure what that means. Some even think that by becoming DNR/DNI, that means withholding care- which is definitely NOT the case.

I had a patient the other day who was quite old, more than 90, with severe COPD, diabetes, and multiple other medical problems. This kind of patient is SO common in the hospital! Well, she was definitely "with it", no dementia, very alert. So I brought up code status with her, especially since she was having a COPD exacerbation and very well may need intubation if she starts to deteriorate. She told me that no one had ever talked to her about it. So I sat down and explained to her what "coding" meant, what we do, and that she can refuse these treatments. I tried not to be too graphic, but of course, it's hard to explain to a patient what a chest compression is without actually saying that we pump the heart by pressing on the chest, likely with enough force to break the ribs. I tried to explain as non-medicalese as possible what the process what, and she could opt out if she'd like. She decided that she would like to be DNR/DNI since she would not want a tube put down her throat to assist her breathing.

How much should be told to the patient? Should we even discuss the actual process and what it entails? Or should we just discuss what their expectations of "life" is, and whether they feel that by being on a ventilator, they wouldn't not be happy living their lives the way they'd like?

I'm not exactly sure of the answer to these questions, and apparently, I wasn't the only one. Even the residents didn't have a "great" way to do this, and they've done it WAYY more times than I have. So if there are any readers out there who have any insight to this, I'd greatly appreciate it. I know there are books and papers out there on this, but I think hearing it from the public may be the best answer.