Tuesday, April 5, 2016

Where's the DNR?

At a duplicate bridge game today, a delightful 91 year old lady I'll call Joan slumped over. A retired Cardiologist at the table, checked her pulse and said she had died. He left to break the news to her husband who lived about 4 miles away. No CPR was initiated because her friends said that she wouldn't want resuscitation and had completed her POLST form (which was in her home).

911 was called and arrived about 10 minutes into the event. I mentioned to them that I didn't believe that Joan wanted CPR. I was told, "Sorry sir, we have to do our job unless we have a spouse or document telling us to hold off."

Joan's friends unfortunately witnessed the technological imperative that 911 calls mandate. Her blouse was stripped back and chest bared, leads applied, an IV started, along with CPR and a few defibrillation shock attempts. Her body was then transported to the hospital where the ER doctor could pronounce that she indeed had died.

The 911 Medics were only doing their job. Joan had done her best by having had the discussions with her providers and her husband. She clearly didn't want resuscitation and had completed her documents, but she happened to be in a place where that wasn't clear. So in a real-time situation like this in a public place where a witnessed cardiac arrest occurs, what could prevent someone like Joan from basically having a medical procedure (CPR) without consent?

Some states have laws that address the issue by promoting the use of DNR Bracelets.  Amazon.com has a number of these listed. So if you are one of the "frail elderly" still active away from your home where your POLST/DNR instructions are kept, please consider wearing such a bracelet. It may not always be honored, but it greatly improves your chances that your wishes will be respected. In the future perhaps we will have a registry, smart card, or other means to immediately find medical information.

Also, please check out smart911.com to see if it's available in your zip code. You can verify your phones and input whatever health information you wish. That way, when 911 is called from your phone, the dispatcher will have your basic information on the initial screen. It's one more important safeguard to coordinate our care.

Update: I found paramedics got Joan's heart restarted so she was placed in ICU attached to multiple tubes and a ventilator and, as would be expected. She is completely unresponsive. I also found out that she's 95, not 91.  The course over the next days included the following: brain scans, neurology consultations, second opinions, testing of brain stem function to determine brain death. But the real need was for the ICU team to bring the family together in a caring way and use family conferencing to attempt to reach agreement to allow her to die. Shared decision making requires experience and training. About 70% of deaths in the ICU are from withdrawal of life support. Joan will likely follow that path. So sad, it's hard to die anymore. It took her 4 more days to die in the hospital.

One bridge player after this event sent a copy of her POLST to the California approved vendor in order to receive this medallion which can be worn as a necklace. 911 responders are trained to treat this as a valid DNR order in California. Other states such as Wisconsin have similar laws supporting the use of certified bracelets or medallions.

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