A DNR is a last resort for people who are terminally ill or injured and can no longer expect any quality of life. Although there are a few exceptions to this, end of life conversations are something that all families should have at some point.
YourBestNightmare asked doctors and nurses of Reddit: Was there a "DNR" patient that you knew could have made it? What's the story?
Submissions have been edited for clarity, context, and profanity.
First, some perspective.
I'm a doctor. I love this question, it's a great place to start. But, I can't answer it the way it's worded.
(DNR = Do Not Resuscitate, just so we're all on the same page)
The real question you have to answer first is this: How are you defining 'made it'? Is that just having a pulse? Breathing without mechanical assistance? Getting your nutrition from a surgically implanted tube? 'Making it' is different for different people.
So, that said, I think you're asking if a DNR order ever stopped us from saving someone that could have walked out of the hospital and lived a 'productive life' for a while longer.
No, I've never seen that happen.
DNR is usually requested by patients that have significant, ultimately terminal conditions. ( Don't confuse DNR with a 'living will', these are not the same thing). These patients have recognized that they've come close to the end of their lives and 'heroic efforts' are, at best, going to prolong their suffering.
It's a huge topic, it deserves much more time than we can give it here.
Also to add to this, there are a good number of times we could "get back" a DNR but the question that gets posed is "how is their quality of life".
Sure 90 year old grandma with cancer could have lived for another 2-3 months but is it going to be that great if we end up breaking all of her ribs to do CPR? If we need an artificial airway do we think she will ever get off or will she need a trache and never eat a solid meal again.
I have worked in the ICU for almost 5 years now and I can honestly say there has never been a case where I said "I wish <patient name> wasn't a DNR" though I can say on the flip side that at least once a weak I mutter to another medical professional "<patient name> really needs to be a DNR"
I've taken to working in variations of the phrase "I can do a lot of things TO your loved ones, but given their overall poor chance for a meaningful recovery, the question is whether I would be doing those things FOR them" into my goals of care discussions. Seems to get at least some people to understand that just because I can artificially extend life using machines for sometimes months at a time, should we actually be doing that.
DNRs are used in extreme situations.
One important thing to consider is that otherwise healthy people usually don't die and definitely don't have standing DNR orders.
That's usually only a code status you get tagged with if you're terminally ill and/or terminally elderly.
We only assign that designation when the patient, family, or power of attorney agrees, and when the patient has demonstrated a trajectory of illness toward unsurvivability.
Some examples of terminal conditions would be:
widely metastatic cancer refractory to treatments, end stage dementia plus acutely life threatening medical condition, cascading multiple organ system failure. Multiple successive critical care admissions over a short interval of time. Progressive failure to thrive at the end of life despite medical interventions and a potentially terminal event. An unsurvivable traumatic injury such as one that results in brain death or uncontrollable hemorrhage or widespread crush injury. Sudden cardiac death with prolonged hypoxia and anoxia brain injury, A massive acute stroke at an age exceeding recovery potential. Diffusely ischemic bowel beyond rescue confirmed surgically. Organ system failure with refused replacement therapy such as someone with Severe COPD that refuses ventilators support or someone with end stage renal failure that refuses dialysis. Patients already in hospice care.
Patients have a right to natural death without heroic interventions and associated expense to their estate should they so choose.
"Making it" doesn't mean having a quality of life.
I'm an emergency doctor, and DNR means do not resuscitate, the decision to place a patient in palliative care or label them DNR is when they have advance disease that cannot be improved or cured as their illness slowly progress and make their living harder and more painful, good examples are advance cancer , advanced COPD ..etc
You know a patient that could've made it? Probably most of them, but what do you mean by made it? Living under mechanical ventilation for weeks in the ICU and not able to wean them off until they eventually die, or living in severe pain/discomfort until they pass away? That would be the outcome if they were resuscitated,
The decision of DNR is not made on the spot, usually by the primary physician who knows their condition very well and know that there is absolutely no improvement or treatment to their current health condition and they try to make them as comfortable as possible.
Most patients/families that I encountered they understand and accept that they know it is a reasonable decision.
Cardiac nurse here. Most people I know probably could've made it, but the quality of life would be so low that living would be worse. Hooked to a ventilator, tubes in every hole, immense pain, TBI, brain dead etc. Very rarely do I see someone make it through a code and be at the same quality of life as they were prior.
My dad had his heart stop for less than 10 min. (Complications after surgery for his cancer). After he came back he was never really the same. The doctors helped him live another year and a half but he suffered a lot and his mental state and capacity were diminished. At the time there was no reason to believe he wouldn't make it and live a long life but the cancer ultimately spread and slowly took him.
Do I regret the extra time spent with him? No. However what I do know is that he would have had way less suffering if he never came back from that code.
With a few exceptions, death is often the most humane option.
Yes. Many patients are DNR plus DNI because many times you can't really do CPR in a hospital without also establishing an airway. We had an elderly gentleman in good shape/health in for severe pneumonia. He coughed up so much phlegm that he plugged his own airway. After multiple failed attempts to suction him orally and nasally when he turned gray we turned to the wife and offered to intubate him solely to remove the plug then immediately extubate him. She refused because she wanted to respect his wishes and he was vehemently opposed to being intubated or resuscitated. We watched him die. That's the only one that really sticks with me as being basically completely avoidable.
The truth is that far more patients should be DNRs but aren't than the other way around. Families really need to start discussing end of life care and expectations BEFORE they need to make that decision. Grandma won't live forever. I'm always a little amazed when people are so confused and dumbfounded that their 88 year old grandmother is dying.
Also it's a total myth that we won't work as hard to save you if you're a DNR or we just want your organs.
DNR does NOT mean don't treat. Even palliative care doesn't mean don't treat it just means that treatment options are more limited and the doctors are really looking at benefit vs risk. Comfort care means don't treat, just make them comfortable and let them die naturally.
Not enough families have the "talk."
It's usually the opposite in my experience actually. More often than not I have patients who are full codes, 90+ years old, advanced dementia, multiple co-morbidities, complete failures to thrive etc etc. And rarely do they have a family member who will advocate for them.
There are a handful of hospitalists that can't seem to bring themselves to know when enough's enough. And they always end up with these patients, and before you know it this poor old man or woman has an NG tube that we all know they goddamn well shouldn't be forced to have, and IV antibiotics for the pneumonia they're now drowning in and and and and.
There is nothing that breaks my heart more than when I admit a patient who's 95+ years old with a broken hip.
There's no telling how long someone will last.
Depends on what you mean by "made it". A decent amount of the patients with DNRs who stop breathing and go into cardiac arrest could be resuscitated and placed on a ventilator, but it's hard to say how long they would last, and their quality of life is usually already pretty grim by the time they get DNR paperwork filled out. I've never provided care for an otherwise healthy patient who stopped breathing and who had a DNR on file with the hospital, and finding a patient who fits that criteria is probably like finding a needle in a haystack.
And then there are the anti-medicine religious nuts.
I'm going to answer this question with a slightly skewed (and perhaps biased) answer.
I saw a young patient (20+) who had been in a trauma whose parents refused to allow us to treat him appropriately, basically allowing him to die. He had lost a significant amount of blood and needed to be transfused. His parents were Jehovah Witnesses and refused to allow him to be transfused. He was given so much saline to bring his volume and pressure up, that when you drew blood for chemistry, it looked like cherry cool aid. It was so serious that they were using vials designed for preemies instead of adults for blood draws. He died of a heart attack because he couldn't oxygenate anymore.
I find it hard to believe that was legal for his parents to make that decision. I know if he were a minor, it would've definitely been illegal, emergency care would've been provided, and it could've been pushed up the ethics chain if the parents strongly disagreed.
Medical staff have to respect a patient and family's wishes, especially religious. This sort of thing happens less and less as there are new alternatives to maintaining life without using blood products but it absolutely happens and is ethical.
You're right. If it had been a minor, this would have been quickly taken in front of a judge to appoint a guardian ad litem. In this instance, the parents of this adult can always say that these were his wishes too, at which point our hands are tied.
This is precisely a case why you need to appoint someone you trust as a medical POA, someone who will respect your wishes even though it may conflict with their own personal beliefs.
(As a side note, this was 20+ years ago and technology has improved)
Those who sign DNRs don't plan on coming back.
As others have said, but maybe I can put it more succinctly, people who are DNRs are not strong, healthy people. Sure, you might be able to revive them for some time, but their quality of life would be abysmal, which is why they chose to be a DNR: they don't want to live with tubes coming out of every hole, artificially keeping them alive.
So can a healthy person request DNR just to be an assh*le?
To be an assh*le to themselves? No skin off my nose if someone healthy wants to be a DNR. I'm not here to judge. It's their life.
This is pretty cool.
My sister was a foster child and the state tried to place a DNR on her due to a seizure disorder that hospitalized her many times. My parents fought them to have it removed. She had a hemispherectomy at age two, learned how to use her body all over again and is now living a very productive life for someone with half of a brain.
I've heard enough of these stories that I push back on the QOL judgement in healthcare. While they're working off a great breadth of info, it's not perfect. Hell, they discovered a woman with no cerebellum that could walk. She was described as "a little unsteady."