posted 09-04-2000 01:00 PM         

quote:

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Originally posted by dbrownuu:
One thing I learned about DNR orders while serving on a hospital ethics committee is that patients in surgery cannot expect a DNR to be honored until the surgeon decides that you are out of his care. Surgeons do not want their statistics messed up by people with their own ideas about quality of life.

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Thanks, DB. One other care-giving group we have heard tend not to abide by DNR orders are the local emergency management techs. In our discussions with hospice, they advise, first, don't call 911 if your spouse wants only palliative care. That's not what the techs are in the business of providing - they will try to save your life, not just transport you to the hospice facility. All our phones now have a note on them to call hospice first.

Hospice also proviides a note to be handed to EMS personnel just in case something happens away from home and some thoughful person does call 911. It is a standard form which should be honored in our state by EMS, so we carry it around in the car.

posted 09-09-2000 02:50 PM         

quote:

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Originally posted by Stamm44:
Thanks, DB. One other care-giving group we have heard tend not to abide by DNR orders are the local emergency management techs. In our discussions with hospice, they advise, first, don't call 911 if your spouse wants only palliative care....

Hospice also proviides a note to be handed to EMS personnel just in case something happens away from home and some thoughful person does call 911. It is a standard form which should be honored in our state by EMS, so we carry it around in the car.

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Thanks for the information, and the idea of having a note (and/or a copy of the DNR?) available to hand to EMS, if necessary.

I will say, though, that I talked about this with an area EMS technician late last year, and she said that most of the services she'd worked for were willing to place a notation, at a likely care-recipient's request, for what she called a "slow code," meaning that they might respond more slowly / not give it the priority response they otherwise would. This seems to me a possible great comfort to both the terminal patient, fearing unwanted and unwarranted resuscitation, and to family members in the household who might otherwise feel tremendous guilt about not calling for emergency help quickly for that terminal relative.

posted 09-09-2000 03:05 PM         

It's important to discuss these things with your physician before you are having to rely on them. Make certain that the doctor understands your wishes and is willing to carry them out. I think this is vital (no pun intended) whether your wishes are for no ressuscitation, only palliative care, or keep-me-alive-at-all-costs.

If there's any possibility whatsoever that your health-care providers WON'T follow your instructions, it's important to have agents who are able to advocate forcefully for you when you're unable to do so firsthand. I assume most people name a spouse, or a child or other immediate family-member in most cases as holder of their power of attorney or health-care proxy, but I have heard it suggested that it might be better, for everyone involved, to grant that responsibilty to a close friend or other relative - that it eases the burden and possible guilt for a spouse or child to have to "pull the plug" on a loved one, and having that responsibility relieved allows the family to "just be family" through this time, and not do double-duty as both loved one and advocate.

I also think it is probably a good idea, when possible, to have alternative or back-up agents named. Not only in case the appointed agent is unable or unwilling to assume the responsibilities, but also because there's a degree of mutual support and reminding one another of the patient's wishes if these heavy matters can be discussed with someone who also understands what you want done.

posted 09-11-2000 03:39 AM         

quote:

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Originally posted by Stamm44:
Get tips from others for making sense of living wills, healthcare proxies, do-not-rescusitate (DNR) orders when making decisions about end-of-life care.

See also a related topic about out-of-hospital DNR orders which was started by Jan elsewhere on the board.

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As a registered nurse, on thing that I have seen over and over again is that living wills/advanced directives are not honored unless the family agrees to do so. In most cases, the living will is used as a guide and not a legal document dictating care. If you have a living will and your family panics, they can reverse it (or so has been my experience)

Also, I saw a posting regarding DNR status during surgery. It has been my experience that the patient and/or family are specifically asked if they want the DNR suspended during the operation. The reasoning is that the opeartion is a factor different from the natural course of the disease.

Honestly, the whole subject frustrates me because I see it abused so often. We live in a society that is paralyzed by the thought of death, much less the reality of facing it. I've had hospice patients come into the ICU because the family has panicked, and that was after they have been educated about the death and dying process. Something has to be done, I just wish I knew what. I think this series is a fantastic start. It's about time these topics were brought out into the media spotlight.

posted 09-11-2000 04:06 AM         

quote:

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Originally posted by Stamm44:
Thanks, DB. One other care-giving group we have heard tend not to abide by DNR orders are the local emergency management techs. In our discussions with hospice, they advise, first, don't call 911 if your spouse wants only palliative care. That's not what the techs are in the business of providing - they will try to save your life, not just transport you to the hospice facility. All our phones now have a note on them to call hospice first.

Hospice also proviides a note to be handed to EMS personnel just in case something happens away from home and some thoughful person does call 911. It is a standard form which should be honored in our state by EMS, so we carry it around in the car.

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Regarding emergency personnel and DNR orders: In New Jersey, when I was an Emergency Medical Technician (1993-1999) were not LEGALLY allowed to honor DNR orders. However, this refers only to Basic Life Support Providers (EMT's, First Responders). In New Jersey, the Advanced Life Support Providers (Paramedics) are allowed to honor DNR orders because they are working under the license of Medical Control (The emergency room physician on duty) It is illegal in this state to "slow code" someone (whether or not you do it is your choice, but know that your butt and license are on the line if someone finds out), and many a time we were called to the house of someone with a DNR order because the person had died and the family did not know what to do. As BLS we had to perfrom CPR until ALS arrived and pronounced the person dead. Of course the family was horrified.

The idea of leaving a note by the phone to call hospice is one of the smartest things I've heard to help families know what to do when that time comes.

posted 09-11-2000 05:49 AM         

quote:

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Originally posted by Robert Lewis:
Some things, in my experience, that people ought to consider in drafting a lviving will, durable power of attorney for health care, Advanced Directive to Physicians, etc.:

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Note: I understand that the ADP must be renewed every X years (2 I think in Texas).
Something to consider.

When I was called to hospital early one morning where my Mother was for colon cancer, the first thing I did was grab her ADP... With it in my hand, I was met by two doctors in the hall way to tell me that she had died of a heart attack. The night before, the last thing she ask for was a cigarette "One would sure make me feel better." -- Ah! A Non-smoking hospital "killed" my Mom...

I'm only 53 and I have notified everyone in my family that I am DNR and my ADP is up for renewal.

posted 09-11-2000 09:56 AM         

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Can I get more information on the "naked" power of attorney that was discussed by the doctor from Missouri?[/B]

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Check out our website which has a lot of resources on advanced directives. A naked power of attorney is also known as a health care power of attorney or a health care proxy.

posted 09-11-2000 12:28 PM         

quote:

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Originally posted by dbrownuu:
One thing I learned about DNR orders while serving on a hospital ethics committee is that patients in surgery cannot expect a DNR to be honored until the surgeon decides that you are out of his care. Surgeons do not want their statistics messed up by people with their own ideas about quality of life.

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Your cautions are well advised, however, I would strongly suggest people check not only their own state laws but the policies of the hospital. In the hospital system in which I work, the suspension of the DNR in surgery and during the first 24hrs post surgery is not mandatory and not the decision of the medical staff.

posted 09-11-2000 10:54 PM         

quote:

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Originally posted by Stamm44:
Thanks, DB. One other care-giving group we have heard tend not to abide by DNR orders are the local emergency management techs. In our discussions with hospice, they advise, first, don't call 911 if your spouse wants only palliative care. That's not what the techs are in the business of providing - they will try to save your life, not just transport you to the hospice facility. All our phones now have a note on them to call hospice first.

Hospice also proviides a note to be handed to EMS personnel just in case something happens away from home and some thoughful person does call 911. It is a standard form which should be honored in our state by EMS, so we carry it around in the car.

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In Virginia, a DNR order (a physician-signed document and a plastic bracelet) means that I and my fellow paramedics don't charge in like the cavalry with CPR, defribillators and a bag full of drugs. We don't ignore this order. It's a legal document. And it's a relief to actually see one when we are dispatched on a cardiac arrest. No 911 provider that I know wants to engage in a futile battle to rescusitate a terminally ill patient. Such efforts, especially with loved ones watching, can be a terribly disturbing. What is more disturbing is asking family for copies of DNR orders and getting blank stares. Arrangements and discussions about DNR orders need to be made well before we come stomping through the door some morning at 3 a.m.

posted 09-12-2000 01:00 AM         

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Originally posted by Rdimont:
However, one thing that I will never forgive is the way her "doctor" made her sign the DNR even though I had signed one for him already. This doctors desire to cover his ass over-rode me and my wife's family wish to provide my wife with with a peaceful death.
Ethically, the doc should have just stood aside and allowed nature to take its course. Instead, he had to push his lousey paperwork in my wife's face on her death-bed even though she was in a state of diminished capacity.
Has anyone else out there been victimized by uncaring docs under the pretense of a DNR?

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posted 09-12-2000 09:22 AM         

quote:

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Originally posted by hafr:
At the beginning of the second program there was an announcement from an organization called "Compassion in Dying" after which a phone number was given. Can someone tell me what that number is?

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That number was a locally sponsored number and was chosen by the local station. Please contact them for more information.

Best,
Debbie R.
Public Affairs Television

posted 09-12-2000 12:21 PM         

quote:

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Originally posted by dbrownuu:
One thing I learned about DNR orders while serving on a hospital ethics committee is that patients in surgery cannot expect a DNR to be honored until the surgeon decides that you are out of his care. Surgeons do not want their statistics messed up by people with their own ideas about quality of life.

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As a physician I feel that the last sentance, "Surgeons do not want their statistics messed up by people with their own ideas..." is somewhat insulting and incorrect. It is true that physicians want to have optimal outcomes for their patients, including statistical representations there of. The reason surgeons want the DNR rescinded for surgery, is that surgery itself is agressive therapy. If the surgery is indicated, so is resuscitation that will allow the patient to recover from the surgery. Ventilatory care during and often following surgery is viewed as a normal part of the procedure and the recovery. To do surgery without anesthia care of the airway is only to be condemned. To operate without the expectation of recovery from the surgery is equally unacceptable.

posted 09-12-2000 12:36 PM         

Physicians are in a bind, however, when the Advanced Directive says DNR, but the family says, "do all you can". I am told that a patient who has been medically determined to be "unable to participate in decision making ( medically incompetent) even by two physicians" has the right to rescind a durable power of attorney or a DNR status. The real answer is that the physician is so do what is medically right and supportable.
:confused

quote:

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Originally posted by Robert Lewis:
Some things, in my experience, that people ought to consider in drafting a lviving will, durable power of attorney for health care, Advanced Directive to Physicians, etc.:

It's important to discuss these things with your physician before you are having to rely on them. Make certain that the doctor understands your wishes and is willing to carry them out. I think this is vital (no pun intended) whether your wishes are for no ressuscitation, only palliative care, or keep-me-alive-at-all-costs.

If there's any possibility whatsoever that your health-care providers WON'T follow your instructions, it's important to have agents who are able to advocate forcefully for you when you're unable to do so firsthand. I assume most people name a spouse, or a child or other immediate family-member in most cases as holder of their power of attorney or health-care proxy, but I have heard it suggested that it might be better, for everyone involved, to grant that responsibilty to a close friend or other relative - that it eases the burden and possible guilt for a spouse or child to have to "pull the plug" on a loved one, and having that responsibility relieved allows the family to "just be family" through this time, and not do double-duty as both loved one and advocate.

I also think it is probably a good idea, when possible, to have alternative or back-up agents named. Not only in case the appointed agent is unable or unwilling to assume the responsibilities, but also because there's a degree of mutual support and reminding one another of the patient's wishes if these heavy matters can be discussed with someone who also understands what you want done.

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posted 09-14-2000 02:22 AM         

quote:

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At the beginning of the second program there was an announcement from an organization
called "Compassion in Dying" after which a phone number was given. Can someone tell me
what that number is?

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Compassion in Dying has a website at: http://www.compassionindying.org/

The counselor at Compassion in Dying was incredibly informative, helpful, and supportive, when my friend died this past summer. She talked to many people in the family and friends, gave me a good understanding of what I could expect to see as I stood vigil with my friend through this, offered advice (largely ignored) to the doctor and nursing home staff, and devoted far more attention to my friend's last few days than did his physician of many years.

I cannot exprees deeply enough my gratitude to the people at Compassion in Dying.

posted 09-14-2000 07:51 AM         

quote:

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Originally posted by hmaicki:

As a physician I feel that the last sentance, "Surgeons do not want their statistics messed up by people with their own ideas..." is somewhat insulting and incorrect. It is true that physicians want to have optimal outcomes for their patients, including statistical representations there of. The reason surgeons want the DNR rescinded for surgery, is that surgery itself is agressive therapy. If the surgery is indicated, so is resuscitation that will allow the patient to recover from the surgery. Ventilatory care during and often following surgery is viewed as a normal part of the procedure and the recovery. To do surgery without anesthia care of the airway is only to be condemned. To operate without the expectation of recovery from the surgery is equally unacceptable.

:confused

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posted 09-15-2000 09:17 PM         

1. Grandfather died last month. Well over 90, he had moved to a nursing home only 6 weeks before since his 80-something wife could no longer care for him. Developed pneumonia, went to ICU for 4 days (4 different IV antibiotics, ventilator). Finally moved to a regular room, discontinued ventilator. Lived 6 more days - as he got weaker hospital wouldn't give him pain relief, claimed morphine would interfere with breathing. Not a good death. Yeah, he had a DNR, but as others have posted the family wouldn't let him go.

2. My mother has advanced dementia. Can't walk, talk, feed herself, chairbound. I will NEVER allow her to be transported from the nursing home to the hospital (signed nursing home form that says no hospital transport, no CPR, no antibiotics, etc.). Biggest fear is that the home will screw up and send her anyway. But, will talk this week with every shift nurse, social worker about exactly what I want for her (I'm health care POA).

posted 09-16-2000 06:02 PM         

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Originally posted by LuckyLady:
I said I didn't want to be a vegetable. Three brain surgeries in three weeks following a massive bleed, three months in a Glascow 2 coma with pupils fixed dialated and non reactive for three weeks of that time. If I know that I'm terminal, I'll take the DNR and living will. I was 39 for the above, and after alot of work you'd never notice the damage. I work, I'm happy, it's not the same, but in some ways it's alot better. Just walking around with a living will, can really end up being the death of you. - Just a thought - LuckyLady

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Lady, it's useful to know that some people do beat the odds - and congrats on your successful treatment.

Nevertheless, for most people, survival after the experience you went through might leave them much worse off than you were and not facing death on their own terms, but on sustained life support in a condition they would not prefer.

posted 09-16-2000 06:09 PM         

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Originally posted by John Silver RN BSN MS:
... If the haelthcare facilities won't do it, the doctors won't do it, and it's unfair to the families, we need another solution. In order to incorporate medical knowledge into the equation, which must be present as well, nursing becomes the obvious solution maker. Think about it.

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JS, thanks for the contribution. I agree wholeheartedly with your comment that the patient and the families need to incorporate medical knowledge into the equation. Nurses are one obvious avenue. Another, though not available in an emergency case, is this marvelous new avenue of communication we are now engaged in. The Internet offers access to vast amounts of information unavailable to the general public or even the educated patient just a few years ago. In the case of chronic illnesses, or even some major killers like terminal types of cancer, patients and families can fill gaps in their own knowledge on the progress of a disease. Granted that it is not always possible to find reliable info, it has been my experience in dealing with cancer info for a loved one that the diligent lay researcher can find good sites which help guide decisionmaking.