End-of-life decision making is a topic near and dear to my heart- it resonates with me because of encounters I had as a nurse when I was young and more recent experiences with my loved ones.
I believe all of us- given a chance- want to control our last days of life. This is why medical counseling is essential to help everyone make informed decisions in advance, including both the elderly and young adults.
But even if you are among the third of Americans who have already done advanced planning, or this is something you want to initiate, there are two other ways to be in control when your life is drawing to a close- Do Not Resuscitate [DNR] and Do Not Hospitalize [DNH] orders.
Do Not Resuscitate Orders [DNR]
The first step to understanding DNR orders is to understand resuscitation.
Resuscitation is a highly invasive event. It can include chest compression, intubation (inserting a breathing tube down the trachea), defibrillation (electric shock through paddles to the chest) and other aggressive measures.
None of this is bad per se. A person in the middle of a catastrophic event- such as an accident- can be resuscitated so that treatment and healing have a chance.
But what if no amount of intervention will restore life? What if death is close and inevitable regardless? What if resuscitation prolongs life in a form the patient doesn’t want?
Some people want to be resuscitated even if their prospects are dim (a “Full Code”). That is their right, and it must be honored.
But for the rest of us? How do we control what happens if we are at the end of life and our heart stops? How do we get to say “enough”?
That is why there are DNR orders.
A Common Misperception about DNRs
Some patients (and families) in the circumstances ideal for a DNR refuse the order because they believe it will stop treatment.
But that is a misunderstanding; a DNR is not an order to stop treatment; it is an order not to stop death if it occurs.
Patients with DNRs receive the same treatments- and in the same amounts- as patients who want a full-press intervention if they go into cardiac arrest. Antibiotics, transfusions, ventilators, dialysis- these things will continue for both the DNR patient as well as the Full Code patient next door.
Which bed you want to be in is a very personal decision, but it should be your decision (or your loved ones’ if you can’t speak for yourself).
If you are interested in learning more about DNRs I suggest these websites:
- American Academy of Family Physicians here;
- Merk Manual here;
- Brigham and Women’s Hospital here;
- An article from Very Well Health “When Is a ‘Do Not Resuscitate’ Order the Right Choice?” is available here.
Once you have decided if you want to pursue a DNR for yourself or a loved one (or possibly to include it in your advanced directive) you will need to find out what your state allows. Ask your doctor, local hospital, estate planning lawyer, or library for more information.
Do Not Hospitalize Orders [DNH]
Do Not Hospitalize orders are much less common than DNRs, and more frequently misunderstood.
First of all- let’s talk about hospitals. Regardless of how great a hospital is, how caring the nurses and doctors are, hospitalization can be a scary, disorienting and lonely experience. That is true for us all.
Imagine now a demented patient who may not be able to benefit from the explanations and caring of those around him in a brightly-lit, loud, unfamiliar environment.
Take for an example an elderly man with advanced Alzheimer’s in a nursing home (residents of long-term care facilities are the most likely population to have a DNH). Would he be sent to a hospital if he fractured his leg, was bleeding profusely or in severe pain? Yes.
But should he be taken out of the place he lives and sent to the hospital (most likely in an ambulance) for a urinary tract infection, a cough, a fever?
A DNH does not make it impossible to hospitalize a person- it is an order to prevent a hospitalization that does not serve the patient.
Who are we to determine what serves this hypothetical man?
That is the point- hopefully he made this decision himself when he was able- long before the Alzheimer’s affected his decision-making.
For the same reason a DNR patient does not want to be saved from death if it happens, there are some people in this state of life (or their loved ones) that do not want to prolong what they believe is a limited existence.
If you are interested, US News & World Report carried an excellent article in 2017 on why a DNH might be a choice for you or your loved one. Remember you will also need to find out what is allowed in your state and how to proceed.
It is common not to want to think about your end-of-life care. Only a little more than a third of adult Americans have any advanced directive at all.
Even so, I encourage you to stop and convey your wishes now- while you can.
Chose a DNR or DNH for your own future under certain conditions if you want- or not.
Either way, you will be right, because this is your choice.
Want to Know More?
- We have all seen reenactments of CPR (chest compressions and mouth-to-mouth breathing) on TV and the movies- some of us may have witnessed the act first hand. If you have questions about what happens during CPR- and more advanced forms of resuscitation using specialized equipment– there is an excellent Glossary of Terms at the bottom of this page about DNRs (hosted by the Brigham and Women’s Hospital in Boston).
- While you are checking in to your state law regarding DNRs- you also need to find out if that order would be in effect outside of the hospital setting. For example, Texas has an “Out of Hospital DNR Form” for people who do not want to be resuscitated in their homes or their community (such as people living in Assisted Living facilities). Find out what your state allows and requires!