Hey there Careblazer. Today I want to talk about a topic that can be difficult for some. The decision of if your loved one with dementia should be a full code, do not resuscitate (DNR) or do not intubate (DNI). Now if you are sitting there scratching your head, you are not alone! These phrases and words are often thrown around in the medical field but not often explained well or at all.
Each of these terms have to do with end of life care.
Making sure that you have made these wishes known to your LOWD’s providers ensures that their wishes are being honored at the end of their life.
In previous videos I have talked about advanced care planning. This is a little bit of a deeper look at terms that are often used in advanced care planning. If you have not watched those videos, I’ll include the links to them below this one.
We are often asked to make decisions about the care of our LOWD but it is very hard to make a decision, particularly about end of life care if you do not understand what the terms mean.
Today I want to review what each of these terms mean and provide a little bit of information about how effective some of the associated life saving measures are.
If you would rather watch a video on this topic, click here.
Ok, let’s get started. There are several different options for end of life care, these are often called life sustaining treatments or LSTs. A life sustaining treatment is any treatment designed to prolong life. Some examples of this are CPR, mechanical ventilation- when a machine breathes for you, and surgeries. So what are some of the terms and options available?
The first term you may hear used is code status. A persons code status is just a fancy way of saying what actions does a person want taken if they were to stop breathing or if their heart were to stop. There are generally three options for a person’s code status: full code, DNR, and DNI. Some hospitals may have some additional options but generally these are the options you will hear.
Let’s start with being a Full Code. All being a full code means is that your LOWD wants everything done to help them stay alive. For example, if their hearts stops beating they want actions to be taken to restart it such as chest compressions or electric shock or defibrillation. If they stop breathing, they want to have steps taken to such as using a tube to help them breathe again.
The next option for code status is a DNR. DNR stands for Do Not Resuscitate. This means that if your LOWD stops breathing or if their heart stops, they do not want CPR meaning chest compressions, defibrilation or shock, or a breathing tube. It also means that medications to help the heart restart will not be given.
A DNR is slightly different from a DNI. DNI stands for Do Not Intubate. In- to place in and Tubate- a tube. To intubate someone means to place a tube down their throat into their windpipe and then using a machine or hand held device to pump air into their body. If someone is a DNI it means that they want chest compressions and medications to restart their heart but they do not want a breathing tube placed.
So you may be wondering, why would someone choose not to have a life saving measure such as CPR? I want to take a minute to go over a few statistics about CPR. I give you these so that you have the facts about these and can make an informed decision. It is up to you and your LOWD to determine what the best option is.
So what is CPR? CPR is cardiopulmonary resuscitation. It is using chest compressions and breaths to pump blood and oxygen throughout the body. Movies often portray overly dramatic instances of CPR being used and effectively bringing the person back to life and then returning to their normal self almost immediately. Movies also tend to portray CPR as a very successful therapy. A study by Mgbako and colleagues in 2014 finding that of the movies they examined, 88% of people were shown to be revived. Unfortunately, this is often not how this works.
The reality is that CPR is often NOT effective. In a study published by Chan and colleagues in 2013 in the New England Journal of Medicine, the long-term outcomes of individuals who received CPR in a hospital setting were examined. I want to focus on the results for those who are 65 or older. Essentially among older adults, only 51% survived. This means that CPR did not work for nearly half of older adults. 34% of those 51% of survivors died before they could be discharged from the hospital. This means that of older adults who received CPR, only 17% made it to discharge. Of those who made it to discharge, only 10% were alive after 1 year.
The other thing to consider is that when someone needs CPR, this means that oxygen is not getting to their brain. Essentially their brain is not getting the energy it needs to survive. As a result there is a good chance that there may be additional memory problems after CPR.
Now again, my goal is not to scare you with these statistics Careblazer, but rather to make sure you have all of the information you and your LOWD need to make an informed decision. In other videos I have talked about the importance of considering the quality of time you want versus the quantity of time you want. I have worked with some individuals who have very specific quantity goals such as wanting to be alive for a wedding or a birth or another special event which has contributed to them wanting to be a full code and I have met others who really value having quality time over prolonging their life.
Ok. Careblazer. as a quick recap: there are 3 main ways in which people choose to address an end of life concern such as their heart or breathing stopping. Those are:
1. Full code- meaning do whatever it takes to bring them back
2. DNR- do not resuscitate- meaning do not do CPR or give drugs to restart the heart
3. DNI- do not intubate meaning that they want CPR and medications to restart their heart but if a breathing tube would need to be inserted that is when they would want attempts to revive them to stop
Another side issue- some people may be DNR or DNI but in an emergency without those papers handy and depending on how they got there, the hospitals do whatever they need to to keep someone alive. In the case of my mom, she was a DNR/DNI and she was intubated immediately upon arriving to the ER by paramedics. but to their defense, they didn’t know. They had not idea. And it’s harder to uphold in cases like extreme emergencies where things are happening quickly.
I hope this information helps both you and your LOWD to decide what is the best option for your circumstances.
Hang in there Careblazers, wishing you all the best for your week!