End Of Life Directives

End of Life Directives

An individual can direct medical care near the end of life as can a health care proxy direct care in the absence of such a directive expressed by the individual. In the case of incapacity this power goes to the designated proxy. The basic principle of end of life directives rests on the inevitability of the prognosis, that the history of the disease will lead to death, and that at certain point, no extraordinary means will be taken to sustain life such as defibrillation on cardiac arrest. These directives should be made clear by the proxy, or by the individual because they can be pushed by the health care system In two standard formats DNR and as DNI.

DNR means Do not resuscitate

DNI means Do not intubate.

(Not all medical environments provide for both options - they should - as they would speciate end of life directives further -: you can have one without the other, for example..).

The popular perception of what DNR means is this: do not apply those paddles and zap my heart if it should stop - let me go. DNI means, if my breathing should stop and I am unconscious and on my way out, do not put a tube into my respiratory tract and breath for me with an artificial device. DNI does not mean do not unblock my airway if it should become obstructed and I am conscious and suffering for lack of air.. The popular understanding of DNI is: do not have an indwelling respirator if I have decompensated to an unconscious state and my illness is terminal. If I am vegitative, and I am non responsive, and not breating - do not keep me breathing artificially. It does not mean: if I have an object in my airway, and I am becoming unconcious for that reason, do not assist me. It does not mean, if have pnuemonia and I am given antibiotics, that I don't want suctioning or oxygen, if it will make me more comfortable and fascilitate breathing.

But are you sure you know what you want? Are you sure of what the health care provider will do and will not do? .Sometimes an understanding means thinking of possible scenarios where your wishes for yourself or another, may be misunderstood. Make them clear.

Neither of these directives means "do not treat me at all." They are very specific. Resuscitation means activel reviving technology is applied in the event of a "code:": respiratory, or cardiac arrest..If you or a loved one is leaving this world, by signing DNR and DNI orders- the medical team is directed not to bring you back.with emergency measures, in the event of cardiac arrest/respiratory arrest. Neither term means "we will not treat if some event occurs other than the terminal illness that might lead to both" such as a person with terminal cancer suffering an adverse reaction to a medication, or - suffering a heart attack, or some other condition that is fixable...

If a person has a heart attack, or they slip into a coma, or they have a terminal illness - they can say they do not want to be revived as the disease is taking an inevitable course that leads to death. They do not want to be “brought back” once they go, when the physiological momentum is - they are leaving this world..

These directives do not mean

“Do not treat me if I get pneumonia”

“Do not treat me if I get a urinary tract infection

“Do not give me routine care”

"They do not mean do not do surgery if I have a problem unrelated to a terminal illness, and surgery will eventually promote comfort."

The terms DNI and DNR also do not mean withhold ordinary care, nor do they mean withhold ordinary medical intervention or emergency intervention. These directives do not mean, ignore me or someone I love.

Health care consumers may be surprised, as the meanings of these terms seem to be unclear to medical professionals. Or if they were clear, they sometimes allow themslves liberal interpretation - re-orient them if you find this is the case. Ask questions...DNR, does not mean ration care, nor is it a rational to neglect - ad lib.

What these directives really mean in principle is: I am dying, therefore, do not bring me back if I am headed out, as I will be much worse for the wear, and I will have to go through it again. They do not mean, neglect ordinary care that will complicate my situation, or fascilitate my death by negelct.

My family was encouraged to sign a DNR order at a meeting for my mother when she broke her hip. I asked her doctor what he felt the DNR meant. His sense was that it meant no extraordinary care would be taken.

But that is not what it means. I asked a hypothetical this way:

“ I've seen my mother having fruit cocktail for lunch and I have also seen her without her dentures, if we sign a DNR order and she should choke on a grape, would you pull the grape out?”

He said “No”

And I asked. “ Do you have a DNI order in this hospital?”

He said “NO”

I said “If you had a DNR order and a DNI order and we signed a DNR order but not a DNI order which would Imply we want respiratory interventions - would you be more inclined to deal with such things as pneumonias and choking?”

His eyes glazed over. He didn't know the answer. His approach was not very specific when he pushed for the DNR. His perception was my mother was old, other things are going to happen and we by signing are not going to intervene by any extraordinary interventions.But that is not what DNR means. I suppose if I had added other hypotheticals we would have seen how ill defined DNR was. I could have asked: "If two aides are assisting my mother out of bed, and she falls, and gets a compound fracture, would you fix the break, or leave her in interminable pain? Would you not intervene and fix the break ...even though the problem is unrelated to her hip or dementia?". What would he have said DNR means then? You have to wonder. A note here: because a doctor suggests something doesn't mean you can't ask intelligent questions as to what he means, or accept ambivalent terms like "extra ordinary care." That term means nothing if it isn't defined..

DNR in this case is ll defined. And it is too unclear in other fascilities I'd imagine. The Health dollar will not be directed to the very old if it can be directed elsewhere - is the new meaning. But it is the elderly who have paid into the health care system all of their lives, they deserve the best care, as everyone does.

The idea to him was "care and comfort.".

I don't imagine it is very comfortable to choke on a grape.So we have to wonder what he means by care and comfort. And the meaning is only clear with tough questions. If you are a health care proxy or a patient do not sign the directive without knowing what they mean by suggesting it.

Here's my point: Many of us have parents who may be near the end of their lives or we may be close to people who have terminal illness. When end of life directives are suggested get clarity on what DNR means... define DNR for yourself and those you care about. Don't let the fascility define it for you. And don't let them interpret it ad lib.

People have the right to spell out what they want done, and what they don't want done in exact terms, medical directives need not be as global as DNR or DNI. .These orders are often just placed on charts on the outside, nurses see the orders: what does DNR/ DNI mean to the nurse. Or the nurses aide?

Until it is clear what you mean by DNR and DNI do not sign those directives. Or if you do sign for a relative as a health care proxy – reinforce what it is you want done, and what you don't want done - to keep the terminal patient comfortable. DNR and DNI orders do not mean “ignore me - do not treat me “ in addition there are specifics that can be reviewed with the health care team.

If you are a proxy for a parent, you may not want a surgery to be done in the case of bowel obstruction in the terminal elderly or you may if the the patient is too uncortable. You definitely was them prevented . If they are not eating or drinking and they are near the end, you may not want IV fluids, or permanent parental nutrition given by way of catheters...you may not want anything extra ordinary or invasive. But are things you may want clear? Make sure your parent gets these things.

For example: the patient may develop an infection, you may want that treated. Directing care near the end of life means being there, and having input. So be there.

On the other hand. You may want bed sores treated, or skin infections treated, you may want IV antibiotics for infections as the IV is only in for a short term. In other words we can define what we mean by “care and comfort”: for ourselves and others, so that there is no ambiguity. This requires due diligence before signing any directives, and monitoring of what the care is when it involves the one you love.

The ambivalence of DNR could be cleared up if a new delineation was made. DND: do not defibrillate. Maybe that directive could be considered.

It is ok to ask what the hell they mean by extraordinary care. There is another poorly defined term. Be assertive, but don't be a pain in the ass...health care providers are often caught between a rock and a hard place, and they have a tough job.

Here are some guidelines that may be useful:

1. When presented with DNR and DNI get clarity on what they mean.

2. Find out if all of the staff caring for your relative knows what they mean

3. Appoint the most knowledgeable health care proxy

4. Define clearly who else can have health care input and insure the health care proxy signs off on your input. ( You don't want to be in a position to have to track down the health care proxy to make quick decisions, ask about multiple health care proxies, multiple decision makers.

5. Explore all of your options by educating your self about end of life directives, including on line resources.

6. If you don't like what you think DNR means to the fascility and you have signed, countermand the order.

7. Please be aware that the presence of an end of life directive does not mean end of care...monitor the care of your loved one, as to it's quality. And, be aware, health care rationing is already upon us. Don't let health care providers make too many determinations without questioning them as to all of their implications. End of life does not mean neglect the patient, or – give up on them, nor does it mean do not fix easily fixable problems especially if intervention will promote comfort. And don't sign anything you don't fully understand ...encourage the hospitals to incorporate DNI orders too - to widen options. As one can have DNR with a definition of what you mean by it, without a DNI. In which case that doctor would have to pull out that grape. ..DNR can be simple. It can only mean, "Don't take those paddles out and zap me back, if I am going out."
   

   Gary Stone BSN MLT ( ASCP)