She’s A DNR
Posted by WhiteCoat on January 23, 2008
Kind of melancholic today.
Did you know melancholy literally means “black bile” and refers to the an imbalance in four “humours” (fluids) that ancient Greeks believed were contained in the body? Read more about melancholy here. But I digress. That’s about the way the night went.
Last night I got bummed out about a patient that I probably shouldn’t have been bummed out about. Ever lay in bed before you go to sleep and have your mind just dart back and forth aimlessly? Sit there and wonder how many calories are in a bacon cheeseburger, think about what you’re going to get your honey for Valentine’s day, and then wonder what the name of your third grade teacher was all in the period of about 10 seconds? I had one of those moments while I was awake last night.
Actually, I did something that a lot of emergency physicians would probably have difficulty doing. I stood in a room and watched a patient die … and I didn’t do a thing to save her.
We got a call at 2AM from a nursing home. A 94 year old lady was being brought in with an elevated temperature. She had the fever for the past 4 days, but tonight was the night she needed to be checked. “Her doctor thinks she has pneumonia … and she’s a DNR,” was the report given to our nurse over the phone.
The ambulance call came about 20 minutes later. “On board we have a 94 year old lady from a local nursing home with a 104 degree fever, possible pneumonia. Short transport time. She’s a DNR, but she’s not breathing so well, so we’re going to bag her until we get her to your facility.”
The ambulance rolls through the door and quickly into a room. The secretary hands me her paperwork and mentions “She’s a DNR.”
I look at the transfer sheets from the nursing home. There are a few medical problems, but for 94 years old, she’s not in bad shape. On the front of one sheet, the letters “DNR” are circled and underlined.
As I walked in to evaluate her, I could tell she wasn’t going to live much longer. She didn’t respond when we called her name and she didn’t move when I gently gave her a sternal rub. She had agonal breathing and wasn’t moving any air. I just stood there for a second. Everyone was obsessed with her being a DNR. This is a woman, for Pete’s sake. She’s a grandmother, maybe a great-grandmother. Someone’s wife. A next door neighbor. The one who always seemed to win at BINGO in the nursing home. Someone who baked cookies for the church bake sale.
Then my mind began to wander. What songs did she used to sing to her kids to help them go to sleep when they were scared at night? What were her fears? Did she know how to bowl? How many people have her picture sitting in their homes somewhere and will forever look at it differently after today? Did she have any co-workers? Would they even know she was gone? How long had it been since she cooked her husband’s favorite meal, waiting to surprise him when he got home from work? It was like I was subconsciously overcompensating for her being a “DNR” by thinking about all the things that made her human. A whirlwind of these whacked out thoughts kept running through my mind.
The nurse snapped me back to reality. “So are we going to do anything with her?”
I looked at the monitor. A couple of blips here and there. I looked at the patient. Her respirations were getting slower and more shallow. I hung my head and gently shook it back and forth.
“Nope … She’s a DNR.”
I stood there and watched her for a little while. I watched her take her last breath. I watched her heart generate it’s last electrical impulse on the cardiac monitor. It felt strange not to be calling out orders for medications and chest compressions. For some stupid reason the whole scenario bothered me. She died in the bright lights of an ED room and the only ones at her side were a doctor and a nurse she had never even met before.
So, wherever you are right now, gramma, heaven has another angel … even if you were just a DNR.
diogorafael said
Wow, it’s such an curious and sad history. I just keep thinking how hard it should have been to you. You passed for a lot in just a few time. But, you know you have to get used to that.
Good luck to you.
Reader 37 said
I’ve often wondered why we (generally) rarely think of people in these terms until they’re dead or dying. What stops us from appreciating people while they’re alive? Maybe the guy who said who said we should “treat everyone like they’re already dead” was right after all.
miztres said
A moving story. Thank you for writing this.
It is too easy to say it is the way she wanted it. She probably didn’t want to go surrounded by strangers, but at least they were strangers that cared enough to give into her last wishes even if that’s against everything they’ve studied or feel. Sometimes that’s all you can ask.
emergencyem said
Beautiful post.
Nurse K said
At the NH Alzheimers Unit where I worked in college, the residents’ rooms all had little photo display boxes where family members put up pictures of them in their youth. So, your questions could have been partially answered…
It was actually somewhat sad to look at the vibrant black-and-white people in the photos proudly leaning up a new car or on their honeymoon and compare them to the thin, confused, incontinent grandmother who had taken their place.
But what a neat idea to show the human side of the patients! How cool would it be to see an old picture of the old grandpa you’re treating in a swimsuit flexing his muscles?
The Happy Hospitalist said
It could have gone the other way. I have cared for a bed ridden, demented 90’s year old who got trached, peg’d and spent months and months in and out of hospitals. The crazy family burned so many bridges in our town, that poor old mama had to be sent an hour away to a nursing home because nobody would take her. Now she comes in and out of that town’s hospital.
The hospitalist at that hospital actually called us once to have us accept the patient for transfer. When we said no, they said. “What the Hell are we supposed to do”.
To that, I say. Figure it out.
As long as Medicare/Medicaid pays for futile care, there will always be that crazy family with unmanaged expectations that will never let go of the living dead.
In this situation, while she was DNR, she should have never transferred to an ER.
There is no such thing as an emergency in a 94 year, if you consider expectations managed.
Agree with the concept, but think that we have to be careful so that we do not take it too far. This was a healthy 94 year old who looked like she was about 70. Do we just forget about her? What if she falls and has a huge head lac? Cracks a hip? Has a subdural? The concept of futility is somewhat like the concept of pornography. Everyone knows what obviously “is” and obviously “is not,” but there is a large “gray area.” Sometimes it is difficult to draw a line between that which is necessary and that which is futile.
jesslev said
WOW- thanks for sharing!
hashmd said
The Hospitalist was right.
For my NH patients, and when I’m on call for my call partners, NO CPR means they do not go to the hospital unless its an obviously reversible condition (broken wrist; yes, even a hip Fx unless they chose “No hospitalization” on their preferred intensity of care form).
I would be doing the same thing you did at her hospital bed if she made it that far. The NH should have been doing the same thing at their facility-following her wishes and letting God or nature decide when to take her.
I agree with your thoughts … to a point. If this 94 year old had pneumonia and respiratory distress, how should she have been treated? Antibiotics? Nebulizers? BiPAP? Vented temporarily? How about if she had CHF? How about a laryngeal foreign body? All are reversible conditions. Treat or not? DNR means “don’t shock me back to life,” not “don’t give me a neb treatment if I can’t breathe.” The problem is that once we start down that slippery slope of not treating medical problems in patients with DNR orders, we can become docs who don’t do anything for anyone over 70 because “if they don’t have a DNR, they need one.”
scalpel said
“What songs did she used to sing to her kids to help them go to sleep when they were scared at night? What were her fears? Did she know how to bowl? How many people have her picture sitting in their homes somewhere and will forever look at it differently after today? Did she have any co-workers? Would they even know she was gone? How long had it been since she cooked her husband’s favorite meal, waiting to surprise him when he got home from work? It was like I was subconsciously overcompensating for her being a “DNR” by thinking about all the things that made her human. A whirlwind of these whacked out thoughts kept running through my mind.”
I honestly don’t let those thoughts inside while I’m evaluating a patient. I know they’re there, sort of like a chilly breeze, but it’s almost like I have a thick warm coat with a hood on to protect me from them.
SeaSpray said
So eloquently written! That must’ve been so difficult for you WhiteCoat. It seems she didn’t suffer with something drawn out and painful. She is in a better place. And you know what? I wouldn’t be surprised if she somehow at some level felt/sensed your compassion even though she couldn’t communicate. And possibly she was already experiencing God or loved ones that had previously passed on. There are so many stories of people who can communicate and their faces light up and they tell their loved ones who they see before they die. You honored her in thought and I believe that energy was picked up.
You also opened yourself up to feel pain by allowing those thoughts in. Maybe on another night you wouldn’t even have the time. You treated her with dignity,respect and compassion. I think life is filled with divine coincidences and maybe you were the best person in her life to be by her bedside when she died.
Thank you for sharing this. We would all do better to remember that people are so much more than the label they have been given.
This reminds me of something I want to put up in my blog at a later date.
Scalpel …your comment was moving too…from another perspective.
God Bless all of you medical people. We need you and I thank God for all the wonderful docs like you guys as well as nurses and all support staff.
Nyuk Nyuk said
SHAME on that N/H, SHAME on the PCP who allowed the transfer….Know that St. Peter added a plus in your book.
Solitary Dancer said
This is a lovely post. After some of my experiences of late, I was beginning to wonder if Docs lost their ability to “feel”. Bless you for posting this experience.
nevins said
A standard nursing home is not a hospice, but death is expected for all of their residents. Most people just want to die at home, whatever that home is. At the nursing home at least she had her acquaintances, friends, and caretakers who knew her. So for her last few breaths, rather than complete their work of easing her into death, they package her up and ship her out.
Too bad. At least they ensured that the DNR was honored. In too many cases, once EMS is activated the DNR is presumed held until proven otherwise. If you don’t want advanced care, don’t call for it. Once called for, then there is the presumption that it is because the DNR has been rescinded.
Nursingassistants.net said
She died in the bright lights of an ED room
White Coat writes about his experience watching an old woman die in an ER. She had been transferred to the ER from a nursing home:
As I walked in to evaluate her, I could tell she wasn’t going to live much longer. She didn’t respond when we called…
Judy said
The nursing home should have kept that last watch – and likely would have had their doc either been willing to stop in or take the nurse’s word for her condition. OTOH, they were watching her closely enough that they didn’t find her cold and lifeless body in the morning. She may have die with strangers, but she didn’t die alone.
TisDone said
Yes – letting her die in peace is the right thing to do – and it does you credit to be able to reflect on the situation so eloquently.
However – I can’t help but have questions. If she had the temp for 4 days, and was already in this state – why did the NH hold on to her for so long? Was she doing great and them crumped precipitously? Did the NH nurses try to get the Doc to okay the transfer on day 2 or 3, but the Doc refused? Had that decision been made sooner – might she have been treatable?
Christian Sinclair said
Thanks for the insightful post. It is nice to see that these thoughts crossed your mind during and afterwards. Many medical people often confuse “Do Not Resucitate” for “Do not provide medical care”, same thing for if they are “hospice” or “palliative care.” By taking this very broad assumption, it is akin to discrimination. Being DNR still allows for a broad range of goals and interventions, so transfer to the ED is sometimes appropriate. As one commenter pointed out you can have a “Do Not Hospitalize” order in place as well.
It sounds like some of the people were trying to highlight her code status along the way to ensure no overly aggressive treatment, but your response after hearing it multiple times is an important one to recognize. You actually “did” a lot by just being present. In our ‘go, see, do’ world we forget that we can help in many ways, including just standing silently by someone and not abandoning them. I also appreciate Scalpels recognition of the armor we clinicians wear to protect our boundaries.
Some other things to do in the Emergency Department at a time like this is get a palliative care team (if available) or local hospice involved, especially if the prognosis is in the several hours to days range, since admission to the hospital or possibly to an inpatient hospice facility might be an option. I just got a mailer for a training course called EPEC-EM (Education in Palliative and End of Life Care – Emergency Medicine) Feb 27-28 in New Orleans. (I’m not affiliated with them, so no kickbacks here). It is interesting because after the original general EPEC course, they unveiled EPEC-Oncology, and the second specialty they decided to approach was Emergency Medicine. You can also be <a href=”http://www.abem.org/public/portal/alias__Rainbow/lang__en-US/tabID__3799/DesktopDefault.aspx”board certified in Palliative Care with Emergency Medicine being your primary boards. So as you can see the Emergency Department and Palliative Care don’t have to be misaligned in good patient care.
Thanks for letting me share the info.
Christian Sinclair said
You can also be board certified in Palliative Care with Emergency Medicine being your primary boards. So as you can see the Emergency Department and Palliative Care don’t have to be misaligned in good patient care.
Sorry, I forgot a few pieces of code for that last link. I wish there was a preview button for comments.
Kimberly (ICU RN) said
This is a sad thing to witness, and you’ll never forget it. I know how you felt here. I’ve been there. On one hand you wanted to jump in and save her life and on the other hand, you followed her wishes. But in the back of your mind, you’re wondering if she might have gotten better and come out of this.
I’ve heard before that some people will wait, and hang on to life by a thread, until their family members are there and tell them it’s okay to die, it’s okay to go. On one occasion I was taking care of a lady who had the works (COPD,CHF,ESRD, etc). She was still responding but was in severe distress.
She had a DNR order.
I held her hand and got close to her ear to talk to her and calm her. No family was around, no one to comfort her when she needed it the most. I told her “I’m here for you, I’m not leaving you. It’s okay to rest now, I’m not going anywhere. I will stay here and hold your hand and stand right here”. Not even a minute later, she stopped breathing and shortly after that asystole. That moment I will always remember.
One of the things I have seen is that often people will die soon after they are told it is “OK to go.” Saw it happen several times with families of patients in the ICU during my residency.
SeaSpray said
Kimberly …if only everyone could have someone as compassionate as you and WhiteCoat by their bedside.
Donna G said
So sad because you know somebody must have loved her at sometime but yet here she was alone.. I used to volunteer in an elderly home.. I was amazed how some were dumped and never visited…
Sad really..They dedicated there lives to maybe kids and family and when they got too much dump.. My grandmother took care of my grandfather with alzheimers until he died and he wasn’t easy.. I admired her… I asked her why and she said he is my sweetheart and I will always love him.(sniff)
DonnaRdh
SeaSpray said
Sometimes people die as soon as the loved ones leave…almost like they are sneaking out because loved ones don’t want to let go.
nik said
My mom is a hospice nurse. She gets many comatose patients whose families are not ready to let go. If it’s bad (lots of bedsores, etc.), and she gets time alone with the patient, she whispers their medical status to their comatose ear, that it’s okay to die and their family will be all right. Often they die later that day. I’m not sure how I feel about that, but if I had to clean feces out of their infected sores because their family wouldn’t, but wouldn’t let them die–I bet I’d say it too.