By Katie E. Golden, MD
As emergency physicians, we often help patients and their families make important decisions about their end-of-life care when faced with a life-threatening illness. The emergency department is never the ideal environment to introduce such critical discussions: the patients are typically too ill to think clearly or even communicate their wishes, their families are in emotional distress over the possible loss of a loved one, and the added pressure of a time-sensitive decision can place a distorted lens on the decision. It is unfortunate how often we avoid discussions and education about end-of-life care until the moments right before possible death.
Patients and their families deserve both time and help navigating their options in the setting of a terminal condition before a medical emergency presses the issue. This article is the first in a series of articles devoted to helping people understand those decisions, and ensure their medical care is aligned with their values and priorities.
I am going to start with an explanation of ‘code status’ and the concept of ‘DNR.’ While this is certainly not the most important question to better understand a patient’s wishes or goals of care, the circumstances in the ED often require it be the first one. What do you want us to do if your heart stops beating, or you can no longer breathe? In other words, what do you want us to do if you are about to die?
What is a ‘code status’?
A patient’s ‘code status’ essentially tells doctors whether or not they want to be resuscitated. Resuscitation is a fancy word that essentially includes all life-saving treatments that bring a patient back from apparent death (aka when they are unconscious and do not have a pulse). This typically requires several immediate interventions to support both the lungs and heart, given both organs are necessary to keep a patient alive. These treatments include:
● Chest compressions (CPR)
● Defibrillation (an electrical shock to the heart)
● Powerful medications that keep the heart pumping (such as epinephrine, sometimes referred to as adrenaline)
● Intubation and mechanical ventilation (commonly referred to as a life support machine).
If a patient does not want to be revived if they are dying, their code status is ‘DNR/DNI’, which stands for ‘Do Not Resuscitate, Do Not Intubate.’ Typically these two concepts go hand in hand (if you don’t want the ‘R’, you don’t want the ‘I’ either), but let’s go through and explain exactly what we mean by resuscitation and intubation.
What is ‘DNR’?
DNR stands for ‘Do Not Resuscitate.’ The ‘resuscitation’ we are referring to in ‘DNR’ specifically references the treatments used to restart the heart, which includes CPR, defibrillation, and epinephrine.
What does the ‘R’ look like?
The process of resuscitation looks much different in reality than the way it is portrayed on TV. While most people imagine it involves a quick and clean shock to the chest (preferably delivered by a handsome George Clooney-looking doctor), the true picture of resuscitation is much more prolonged and messy. (And I, for one, look nothing like George Clooney.) Patients and their families should understand several key points about resuscitation:
● It often takes a long time to get the heart started again, which can often mean 30 minutes or longer of continuous CPR.
● CPR requires a significant amount of force on the chest in order to effectively keep blood pumping through the heart. This can result in multiple rib fractures when performed correctly, particularly in enderly or frail patients.
● An electrical shock to the heart is not always effective, and some patients require several rounds of shock if it is going to work.
● While the patient is most often unconscious during CPR and electrical shocks, these are painful treatments and can result in significant injury to the patient. A few broken ribs is certainly a small price to pay for a saved life, but patients should understand the details of these treatments when deciding whether or not they want resuscitation.
What is ‘DNI’?
DNI stands for ‘Do Not Intubate.’ Intubation is a procedure that is performed if a patient is having difficulty breathing, or cannot do so on their own. It requires that we place a breathing tube down the patient’s airway and into the lungs, and then connect the tube to a life support machine. Intubation is almost always a part of the CPR process, and is either performed while the patient is receiving CPR, or immediately afterwards if the CPR successfully restarts the heart. (Side note: This procedure is not just reserved for patients who ‘code’, and it is often performed for patients for patients who are unable to breath well on their own.)
What does the ‘I’ look like?
Intubation requires the following steps:
● If the patient is conscious, we administer a medication that is highly sedating so that they are comfortable during the procedure.
● After the patient is unconscious, we give them a medication that briefly paralyzes their muscles. This prevents them from clenching their jaw or gagging on the breathing tube as it passes down the throat and into the lungs.
● Once the breathing tube is successfully placed into position (using a special device that allows the doctor to open the jaw and see the airway), the tube is connected to a breathing machine, or ‘mechanical ventilator.’
● The patient is started on a steady delivery (or ‘drip’) of sedating medication so they remain unconscious and comfortable as the machine does the breathing for them.
Just like CPR, patients and their families should know several things about the procedure:
● The patients need to remain on the sedating medication while on the ventilator, as it is quite uncomfortable to have an external machine in charge of your breathing. This essentially means that the patient is unable to talk or communicate while intubated.
● It is difficult to know how long a patient will need to remain on the ventilator to recover, and it can be days to weeks or even months before they are strong enough to be ‘extubated’. In the most severe cases, the patient never recovers the ability to breath on their own.
● Intubation is an inherently dangerous procedure, as it requires the doctor temporarily paralyze the patient (and thus take away their ability to breath on their own) before securing the breathing tube. There are several complications that can arise mid-procedure that make it hard to successfully place the tube. This could result in a prolonged period without oxygen, which can subsequently result in organ damage and even brain death. While these complications are rare, they are possible even with skilled and experienced doctors who perform the procedure correctly.
● The more common, but less dangerous complication is damage to the teeth or throat during the procedure. While not life threatening, patients can sometimes suffer chipped teeth, throat pain, or damage to the vocal cords making it hard or painful to talk after intubation.
Resuscitation may sound scary and grim, and these descriptions are certainly not intended to dissuade a patient from being ‘full code’ (the opposite of DNR/DNI). As doctors, we want nothing more than to save our patients and make them well again. For patients with a terminal illness, however, it is important for us to be transparent about their treatment options so they can make the best decision for themselves. Sometimes the best way we care for our patients is to focus on improving the quality, not quantity, of their days.