The Solution Nobody Will Mention: DNR

By Steve Haner

This is how we solve the coming hospital bed crisis. This is how we stretch our ventilators supply. No politician is going to say this, neither Donald Trump nor Andrew Cuomo, and doctors won’t start this conversation. Lester Holt won’t bring it up on Nightly News.

It is called a “do not resuscitate” order. DNR. It can stand on its own or be part of package of advance medical directives and powers of attorney. If you don’t have one, sign one. If you are 40 and think yourself healthy, consider one anyway. Today. 

It may not solve the problem but it surely will help.

Most people who are dying are not dying of COVID-19, they are dying with COVID-19. Yes, there are outliers, but most people who cannot survive this virus already had an underlying problem.  It might be a 65-year-old with COPD from smoking, two by-passes, or half a lung removed for cancer, or it might be a 30-year-old who vapes or who has already eaten themselves into diabetes and hypertension.

Say you have signs of this infection but are late calling for help, you are in the ambulance on the way over to the hospital or are already there, and your heart stops. The medical people, absent a DNR, will immediately start CPR. Pressing down on your chest will expel air ripe with live virus. You have infected them while they save you. Do you want that?

A DNR doesn’t mean you don’t get a ventilator (unless that is your directive); it means you don’t keep it beyond the point where hope has faded. It means they don’t revive you from a heart attack, then leave you comatose on the ventilator. Again, there are outliers, but the docs and nurses know pretty quickly which patients no longer have a real chance. With an advance directive, they will start the conversation. With a DNR, if you suddenly “code” with cardiac arrest or pulmonary collapse, no efforts are made to bring you back.

You know this would free up desperately needed ICU beds all over the world, right now, this minute, yesterday. Unless the patient comes in and the DNR or advance directive is on their charts or communicated by a family member with power of attorney, our medical culture goes into overdrive to save them. I would be terribly upset if such efforts were made for me when a ventilator could save somebody else. If a family member says the same to you, honor it.

My daughter is not on the front lines of this crisis but has spent quite a bit of her career with patients fighting for life against cancer, and their families who won’t let them go. No, friends, that fourth round of chemo that costs $200,000 and buys you 60 days, 40 of them miserable in hospital, is not a good idea. This is where our medical system is most insane, at the very end of life.

This medical crisis has revealed many weaknesses in our system, often problems that people really didn’t anticipate. Those fancy N-95 masks were developed mainly for dealing with tuberculosis, all but eradicated in many parts of the world. The fact that doctors cannot get them while Internet pirates sell them on eBay can solved by arresting the pirates and confiscating their goods.

What it has revealed about our politics is sickening.

But this crisis is also revealing a weakness in ourselves, an unwillingness to face cold reality about our own finite existence. COVID-19 is a nasty bug, but it is mostly killing people who are already in trouble from other things, sometimes not their fault and sometimes entirely their fault. (If Altria doesn’t reopen, that won’t bother me one bit.) The worst strains on the hospital system may come from maintaining life after there is no reasonable hope for recovery.

Sign the DNR. Fill out an advanced directive. If you have grown kids, tell them about your decision. If you don’t, tell the sibling most likely do go screaming to the doctors seeking every effort to revive you. If every emergency department admission for COVID-19 from now on is accompanied by that kind of advance permission to withhold treatment known to be ineffective, it will make a difference between now and the peak.

Most of us geezers have faced this (some face it and still refuse to sign, but we’ve all thought about it.) We’ve seen what our grandparents, parents, aunts and uncles went through at the end, long before this crisis. This particular disease pushes the conversation to earlier stages of life, but that’s a good thing, too. Our lousy lifestyle means age is no longer the only risk factor. (And now we can’t go to the gym at all….)

Don’t waste an ICU bed or ventilator. Sign that DNR today. If you already have one, pull it out to be ready.

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24 responses to “The Solution Nobody Will Mention: DNR

  1. Perfectly said, Steve.

  2. We faced this when my father was dying if congestive heart failure in 2004.

  3. The proverbial “death panel”, eh? It’s a panel of one, but it’s the one you trust the most. Okay, you’re right, AND you’re wrong.

    Right, many times those, who are resuscitated, only linger comatose until someone is forced to pull the plug, however this is mostly for people ALREADY hospitalized, or with KNOWN conditions.

    Wrong, many of us, even those of us over 60, relatively healthy and who suffer a catastrophic event can recover (anecdote: My 80-year old cousin was playing tennis and suffered a heart attack. His 56-year old wife, a former EMT grabbed the defibrillator, and shocked him back. Six months later, they were again playing tennis. That was 5 years ago.).

    Don’t just SIGN one without discussing with YOUR doctor and try to include various conditions to help your doctors decide with your wishes in mind.

    Plus, revisit it often. Things change. Conditions that would have resulted in death, or a real “vegetarian lifestyle”, 10 years ago are being overcome by treatment today.

    • “Death panel.” Yep, that’s the problem attitude. You’d be one of those shouting at Lt. Gov. Patrick in Texas. Didn’t take long. I’m not even partly wrong, and perhaps you’ve never read a well written medical advance directive. It does not say make no reasonable efforts. Personally we have advance directives, and mutual powers of attorney for if we are incapacitated. Luckily we have an NP in the family. But if I were on my way to the ER today suspecting COVID, I’d sign a full DNR.

      Your cousin didn’t have a lung full of COVID-19.

      • Not me. 2005 I suffered an acute respiratory something or other. It was never fully diagnosed to my satisfaction, but it was treated and has not been an issue. At this point, I believe I have had a lung full of covid. On March 4 the spouse and I headed to Florida. Spent 4 days at Universal Studios and 4 in Key West. On the 15th, I developed a sore throat, on Monday it was raging sneezing and snot-slinging like I have never seen. By Wednesday, I could barely breath and Thursday and Friday I slept at the table since I could not lie down. The spouse’s symptoms ran 2 days behind mine. Never a fever, so without hospitization a test would not have been given.
        When an antibody test becomes widely available, we’ll test.
        Point is, not every person going on ventilation is dying, a large percentage don’t, so without an underlying condition, I’ll trust my spouse and daughter armed with their POAs.

        • My prayers!…but you basically say what I’m saying, I have the paperwork, my wife and daughter know my wishes. You may very well be a survivor. They’ll want your blood!

      • Btw, I did yell at Dan Patrick. Money can be replaced.

  4. It’s a bit of a maudlin subject but very appropriate for the times we are in unfortunately.

    WaPo actually did have an article about it but in a “death panel” sort of way:

    Hospitals consider universal do-not-resuscitate orders for coronavirus patients

    https://www.washingtonpost.com/health/2020/03/25/coronavirus-patients-do-not-resucitate/

    I’ve done an AHD – Advanced Health Directive – the hospital was proactive about it for all admissions at that time I was admitted for a one day stay. I forget now what they actually did with it but I think it did go into a State maintained electronic system. (Might be useful to show that if it does exist).

    We had an acquaintance that passed recently – she had stage 4 in her intestines, her mother had died of it and she decided she would not go
    through what her mother went through and took her own life at home.

    Perhaps not recognized, more than half of gun deaths are suicides and a good number of them are suspected to be related to a chronic disease.

    • Sorry about your friend. A wise woman. My father in law’s end was marked by family bitterness as he was suffering and wanted to go, but his wishes were disputed.

  5. Here’s how in Virginia and it ought to be available to most hospitals. This
    is a way to NOT have your relatives searching through your papers trying
    to figure out where it is and if it is the last one done.

    Commonwealth of Virginia Advance Health Care Directive Registry. Use this secure tool to store important documents that protect your legal rights and ensure your medical wishes are honored if you are incapacitated and unable to manage your own care.

    https://connectvirginia.org/adr/

    there is a provider login also:

    Provider Login
    Login here if you are a healthcare provider looking for your patient’s registered Virginia Advance Health Care Directive Registry documents

  6. johnrandolphofroanoke

    I know a fella that has DNR tattooed on his wrist. That would make things crystal clear to everyone. As for me I intend to go down swinging like Snowden Andrews. This man was disemboweled at the Battle of Cedar Mountain. Surgeons refused to sew him up. Andrews was declared mortally wounded. He convinced the doctors to clean the wound, place his guts back where they belong, and sewed Andrews back up with a calico needle. Declared dead August 9th and back to duty October 12th. Lived to see the 20th century. Famous Baltimore architect and urban planner.
    http://www.aphillcsa.com/snowdenandrews.html

  7. I totally agree with you, Steve. Signing a DRN is not just a practical way to cope with the pandemic, it is the moral and ethical thing to do.

    My wife and I both have signed DNRs. I’m not sure how the logistics of this work, though. It’s not like I’ve tucked a copy of my DNR into my wallet. It’s sitting with other legal documents in a safe. I presume that docs and hospitals will want to see a copy before pulling the plug. I guess that means I’d better not forget to bring my DNR with me!

    • Fully agree with Steve and two Jims. I fought and won two very tough battles against the medical establishment to insure those I loved got their rights (expressed clearly in DNR) to die in dignity, instead of being converted into cash cow paying victims of medical establishment. 2nd battle was over a ventilator whose unauthorized and attempted coerced use was refused wherein I had to override three doctors.

  8. Another approach: National POLST Form: Portable Medical Order

    good article in NYT:

    The Trouble With Advance Directives

    https://www.nytimes.com/2015/03/17/health/the-trouble-with-advance-directives.html

  9. Don’t sweat it. Corporate hospitals and insurance companies will determine when your bank accounts have suffered enough.

  10. In the western part of Virginia, the Carilion System has a systemic way of maintaining Medical Directives. They check with patients regularly and have a central computerized storage.

    My brother was killed in a farm accident when he was 7 and I was 11. The first thing my parents said to us was that he’d been without blood to the brain for long enough that if he’d survived he’d have had major issues. Thus my attitude was shaped from an early age in support of DNR in hopeless situations. Granted, we can’t always tell, but often the data line up.

  11. There’s several ways of looking at this, and I can certainly sympathize the risk of resuscitating a COVID patient. It’s much easier for a 75 year old to rationalize their own end having lived a pretty full life, than it is for someone like me. I’m in my early 30’s, healthy, a small child with another on the way. There’s no scenario I’ll be signing a DNR.

    • Now, you are just starting to understand the tragedy of a young soldier, sailor, airman or marine, dying on a field of battle.

    • You’re young and have not yet confronted the idea that something could happen to you – and you end up essentially a vegetable costing 100K a month to keep alive.

      It happens to 30 year olds too.

      And the question is – what would you want your family to do if they had to pay that 100K a month?

      No easy answers and it’s not just about old folks.

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