What Does That DNR Really Mean? w/Dr. Fred Mirarchi | Incident Report 246

[@melloyello7349]

Can attest to this that the words heard coming out of a residents mouth when told about a change in status was “well he’s a DNR”. To this day it still gets to me.

[@genehobbs1825]

Great discussion... it is a hard one to have and something not all teams are comfortable doing. Thanks for tackling another huge topic

[@margiestasik8788]

Every nurse I've worked with knows "end of life" does not mean DNR. We educate patients and families r/t need for specific DNR orders and that they can be changed according to patient's wishes.

[@ferdinandomirarchi5539]

The research would suggest otherwise

[@masrjk53]

@@ferdinandomirarchi5539 I'm sorry I have not replied sooner. Living wills are generic, they do not provide nuances and specifics. Our patients and families are made aware that their decisions can change per their desire. I have had many patients that wanted DNR, but when they are seriously declining and fighting to breathe change their mine; and families for patient's incapacitated will ask for the DNR status changed. Physicians have told me the patient will not be able to sue, but the families can. I'm serious, that is a direct quote when I questioned their rationale. Maybe this is a regional problem, but I've experienced this at a tertiary teaching hospital and at a community hospital in Ohio. I have taken care of nurses in their 30s that made themselves DNR and were experiencing a condition that is treatable and we had to instruct them on the treatability (pneumonia) and finally when they are close to death will agree with stipulations to allow intubation to save their lives. I have 2 RN friends that adamantly refuse to be resuscitated, one committed suicide, the other wants to live---her decision but she knows I worry about a 30+ year old preferring to die than be resuscitated. The ER docs and nurses adamantly refuse to be resuscitated and think I'm weird because I do. I have told them "I want to live". I don't care about the statistics of survival-it is relative to the problem that requires resuscitation

[@TanyaBoser]

Thank you for this intelligent discussion with some well thought out and researched suggestions for dealing with this. I am an ER nurse, and yesterday had to deal with this for two terminal cancer patients. Thankfully, we have a good team that understands the nuances, most of the time. One of those terminal patients had not ever had the Advanced Directives conversation with family at all, and did not have a POLST, and we had to intubate when the patient went into respiratory arrest with no hope of the patient ever surviving extubation. The other was in respiratory failure, had a POLST, no family present, and the patient still verbalized forcefully no intubation, which agreed with the POLST. That patient was still treated aggressively for sepsis, which agreed with the POLST guidelines. The second scenario is how the system is supposed to work.

[@MellyBelle]

I am grateful that the culture of my workplace is that we understand that DNR does NOT mean do not treat. I'm surprised and disgusted that is not the case everywhere. The video format to describe one's treatment goals/wishes is a great idea.

[@ferdinandomirarchi5539]

Don’t be overconfident in your system. Look and you will see misunderstandings exist.

[@adobrowolsky13]

I have seen the DNR means “do not treat” attitude among health care professionals, even though I’ve been a nurse for a short time. I work in a rehab/nursing home facility and this can be the way of thinking for elderly or very sick patients. I don’t agree with this, and I have worked with many patients who ask about their options and what end of life is about. Thank you for bringing more attention to this issue and working towards fixing this rampant issue in the healthcare community.

[@ferdinandomirarchi5539]

Thank you for your honest comments

[@audreylaferriere]

I do not know why this video has not gone viral. It is so important.

[@ferdinandomirarchi5539]

Thank you! Help us make it go viral

[@dconnett8770]

Great discussion. I have had patients who feared being kept alive on a ventilator signed a DNR became septic needed to be admitted to the unit and CNO came to me why are you putting a DNR in the unit? DNR does not mean do not treat.

[@littlejimmyyouman7201]

This would be great to adapt for dementia patients, who may not want to be treated but can no longer express themselves.

[@ferdinandomirarchi5539]

We have many dementia patients and have also utilized this for those who are acting as the agent for a patient with dementia

[@DrAdnan]

It’s sad when people don’t get the end of life they wanted, whether it’s due to healthcare provider lapses or other family members.

[@Kisdaddy11]

Zdogg talking about stuff no else wants to talk about.

[@katecastellano5355]

This is an area where medical social workers and doctors can work together. Love the video btw

[@kathybrady4033]

Super scary. I am a physician myself and put myself down as FULL CODE here in CA. Anything less could be terminal when I have something short term which could be resolved. I will ONLY add a DNR when I KNOW I have a terminal illness in the advanced stages. Otherwise you may be kissing your a** goodbye after a cardiac arrhythmia, botched surgery, etc etc.

[@DRnab1983]

Kathy Brady agree- DNR , so often is taken as don’t prioritise , no sweat -,

[@suzalpacadream]

So what can we do now to give ourselves the reassurance of not living on a vent in case of the unforeseen ? My worst nightmare is living the way I see some people do after leaving the hospital. Do I just write a letter to my family and give it to each of them?

[@kathybrady4033]

@@suzalpacadream Hi Suzanne, I would see a Trust and Estate attorney. They can help you fill out the complex forms which spell out each possibility (do you want antibiotics? Yes Dialysis? Yes Ventilator? Yes if conscious, No if brain not functioning....etc...Who is your designated health proxy? Sister, friend, hubby, etc....Also you can draft a letter and send it to each person who means something to you. The whole process may cost about $2K but so worth it and can be updated for a few hundred every couple years as relationships change. Make many copies. Give them to all parties and to your regular doctor. Keep them at your home and in your glove box. Give one to your spouse. Otherwise it is hard for the docs to follow them!! Good luck to you. Also realize that in the moment, if you are not able to decide for yourself, your proxy can override the stated wishes at any time if things look worse or more promising to help you with the outcome. So there is a human element. Be well!!!

[@AnthonyBrusca]

In the last few months, I've been to a hospital many times. I have only ONCE been asked if I had a living will and that was the one time I was doing outpatient testing. I was even admitted and when I got a copy of my records, they signed I did not have one and they didn't even ask. ALL because I am 22 and they ASSUME I do not have one. I do. It is not a DNR, but I made it specifically to not let my next of kin make my decisions.

[@curlybibliophagist2]

Kudos to you! I've seen young people caught in bad situations because they haven't made their wishes known. Btw, a DNR is for someone with a life expectancy of

[@merkinidgit]

I work on neuroscience and we get a few young adults with strokes, migraines, TBIs, and tumors. I always ask. Its usually "no" and I advocate for the importance of advance directive at any adult age.

[@merkinidgit]

@@curlybibliophagist2 A DNR in my state, and the other states in which I have worked as a nurse, is for someone of sound mind and majority to indicate their resusc wishes, regardless of life expectancy.

[@AnthonyBrusca]

@@merkinidgit The shitty thing is that I only had to do it because I do not believe in a DNR at all for someone my age. My mom disagrees. So much so that she will go against my wishes and pull the plug if I crash my car or Motorcycle and end up in a coma.

[@kathybrady4033]

Basically healthy adults should not sign ANYTHING other than POLST indicating every possible measure should be taken. Of course I want to be on a vent with a Foley and an ICP monitor if I got hit by a car and I am likely to recover!! It scares people unnecessarily to tell them about the big bad tubes and beeping machines. Those machines may allow you to attend your granddaughters wedding rather than your own FUNERAL!

[@iamReddington]

Having multiple types of DNRs is the problem. DNR for cardiac arrest, but not for a car accident that has you on your death bed? DNRs were never meant to be broken down into multiple sub categories. DNR is a flat out do not resuscitate. If you don't want to be revived, get one! If you want ti live, don't get one. Having sub DNR categories where you want to be revived in this scenario, but another is just going to cause more problems. I'm almost 30 and have a flat out DNR. If I got resuscitated simply because some idiot didn't want to respect my wishes, or they wanted to claim the DNR said this or that, I'd sue the shit out of them. I have a DNR for a reason, as do many others. DNRs need to be fixed so it's a flat out DNR = no resuscitate, period. No stupid "I don't want to be revived for this, but I do for this."

[@Sami-qk8sq]

Red Reddington Curious how you feel about if you were to go into cardiac arrest out in public and a Good Samaritan were to provide CPR... I believe there is a law that protects a Good Samaritan If the perform CPR in public.

[@iamReddington]

@Sami Michelle if I'm out in public and it happens, I'm going to be mad I was revived by said samaritan, but I wouldn't be mad at them. I'm all for people doing the right thing and trying to help others.

[@Sami-qk8sq]

@@iamReddington Okay, that makes sense. Thank you for your response!!

[@justinelindsey3724]

DNR for u and u and u

[@sheilahill5492]

How do we get this MIDEO on our pts. Charts??!! This is an amazing idea!!! This is the first time I've heard of this. Can we possibly scan it onto Epic??

[@xXxSapphir3xXx]

Providers ask and bring up code status prior to deciding tx quite often. I've never understood why this matters - DNR does not equal Hospice comfort care only, yet it does for some. My mind is blown everytime I see this, especially for treatable dx, like a complicated UTI to urosepsis... When talking to my parents and family, I've encouraged them NOT to sign a DNR for the Do Not Treat behaviors and instead have promised to honor their wishes when that time comes.... I agree with not doing full code Hospice - it doesn't make sense and sets us all up for failure.

[@lohphat]

What if that patient scenario at the start didn't want to be resuscitated by the cardiologist? It may have been her 3rd cardiac event and didn't want to go through it again and the cardiologist just ignored her wishes. The RN wouldn't have had the DNR in her hands for no reason. This doesn't seem like a "treatment" issue as it was a critical event and apparently she indicated she didn't want another round already. Did she have a specific details in that DNR?

[@lisaswantek6453]

I am located in Erie! I would love to know where your office is located.

[@grendelum]

1:35 Keyword: *Collaborative* The “big thing” we found in the renewable energy industry was that our disparate disciplines fostered collaboration between unlikely partners which lead to new innovation. When individual groups work together your voice (and bargaining position) becomes stronger... workers of the world unite and all that. One thing I am sure of, *Fred Rogers* knows y’all are being the best people you can be.

[@lohphat]

As for the last scenario of the elderly woman having cardiac arrest in front of you and you let her go, the alternative would have been worse. I've done end of life care and the last few days of life is not pretty be it via disease or natural causes. The cessation of food and drink, the dehydration, inability to swallow, the labored breathing... She just checked out probably not knowing what hit her -- which is what shekind of told you she wanted. You did the right thing. I have my living will done and I can tell you, if I can avoid the last 3 days of my life and the trauma that causes carers and family, I will.

[@curlybibliophagist2]

That is so cool! How do I get a card like that?

[@chanvalentine8283]

My mom, had a medical directive if she had complications after surgery, and she also had a DNR. The DNR, thankfully was respected. She was a type 1 diabetic, blind, blood pressure issues, and the melain sheaths were coming off of her nerves into her gut. She didn't have the third stint placed in her heart from the heart attack. So, she left via a second heart attack 7 yrs later.

[@ferdinandomirarchi5539]

Very sorry for your loss

[@chanvalentine8283]

@@ferdinandomirarchi5539 Thank you.

[@RabblesTheBinx]

DNRs are always a tough thing, especially because patients don't always understand all of the options. My dad was explicit in wanting everything short of intubation done to keep him alive (his exact words were "I don't want to be soup on a machine with a tube that won't come out"), but when he was in his last week of life, we had him placed on BiPAP, cuz it wasn't intubation, but he couldn't stand it, but he was so hypoxic that his mind wasn't working properly, he didn't recognize me or my stepmother, didn't recognize his friends, and we finally had to take him off. It was the hardest thing to watch him literally suffocating to death. I still wonder, sometimes, if we could have let him die more comfortably if we had just forced him to stay on the machine. It was just so painful for him, and you could see it on his face. He was like a fish out of water. I wish assisted suicide had been an option in California, so that he didn't have to suffer.

[@RabblesTheBinx]

@Marc Robin Gruener I mean, he was in complete respiratory failure after a 12-year battle with emphysema; his lungs were completely non-functioning, so there wasn't really anything else that could have been done, it was either life support, or let him die. It just sucked that it had to be a painful death due to physician-assisted suicide being illegal in CA. That, above all else, is why I think right-to-die laws are necessary.

[@RLybarger1986]

Honestly, this story is where someone could have advocated for 'comfort measures' (such as pain meds) which relax and cause respiratory depression. He did not want to be on a tube but he should not have been allowed to suffer.

[@RabblesTheBinx]

@@RLybarger1986 he was in hospice, he was on pain meds. Doesn't do anything for hypoxia at that level. He literally could not breathe on his own. When I said he looked like a fish out of water, I wasn't exaggerating. The only way pain meds would have helped is if they'd given him enough to kill him, which is illegal in CA.

[@RabblesTheBinx]

Trust me, we looked at every possible option. We're talking about someone who had literally 0% lung function.

[@curlybibliophagist2]

@@RLybarger1986 palliative care or hospice. They are such a godsend.

[@greggatchell9255]

Great discussion!

[@GlennOsborne]

Thanks so much for this, I’m a big fan of your videos. This is the precise reason that I don’t have an advance Directive. I was a nurse for over 30 years and have seen and heard far to much to trust these things. I am going to be looking into the Mideo Card for myself as well as family members.

[@GlennOsborne]

Marc Robin Gruener thank you I have visited the Mideo Card website so now I will have a look at the other one.

[@GlennOsborne]

Marc Robin Gruener where are the interviews held for the Mideo Card?

[@GlennOsborne]

And what are the out of pocket costs typically with Medicare?

[@GlennOsborne]

Marc Robin Gruener Thank you

[@Markh-fp5du]

Guys, guys, simple solution. Open an in-house tattoo shop, offer all discharging patients a free, decorated to suit, small checklist tattoo. *With appropriate discussion prior* : ETT yes/no, ETT 2-3 days yes/no, Apache score >X treat/don't, plus socsec/Medicare numbers, whatev. Flowery but readable, universal location on the body.

[@ParadigmAudio]

Thank You.

[@hollyroden5169]

Thank you for this video!

[@autumnm2075]

This makes me wonder about my advanced directive, and how it compares to a living will.

[@IceLynne]

This was very informative, thank you.

[@codygleason40]

Would be a good program for Kaiser scene everyone all ready carries around a Kaiser card

[@HH_The_Great]

Could you please give us Muggles a description of the abbreviations and acronyms your guest is using? Thank you. 😀

[@patientpathwayscanada]

Hey Holly, I sure understand where you're coming from. I'm immersed in this stuff but still didn't understand a few of the acronyms. If it was written text, they could take the time to tell you what POLST stands for - Physician Orders for Life Sustaining Treatment or No CPR (don't do cardiopulmonary resuscitation) versus Do NOT Resuscitate (DNR). Most physicians don't understand this stuff, hence the errors they talk about. But, I'm sure you get the gist. Good for you for educating yourself.

[@HH_The_Great]

Thanks, Connie Jorsvik!

[@pokegeaks2]

What about people who can't speak?

[@chrisb1975]

So does a healthy person who travels a lot make these tools available in a fashion that if I’m in another city and something bad happens, that facility that doesn’t know me like my local doctor or hospital that has this info on file. Is there some sort of national clearinghouse house type of system that is checked for this sort of thing? if not, is something like that possible? Since most states have organ donor registries, does it make sense to try and get state governments to expand their systems to store an electronic copy of this type of information and share with medical facilities? I could see it as a voluntary service available for a small fee to cover the cost. Its not very practical to carry around that paperwork everywhere I go. I have tried carrying a usb thumb drive in my pocket with Adv. Dir. and a red cross drawn on it, but is someone treating me actually likely to find it? Am I going to remember to always have that on me? What if I am at the beach or swimming pool?

[@chrisb1975]

Marc Robin Gruener Dr. M responded to me on Twitter on a similar post I made there. This is brilliant! May seem odd and I may be one of the few reasonably healthy patients that is pretty passionate about how important it is for everyone, young or old, healthy or not, to have good solid advance directives in place. I saw elderly family members as a kid have their wishes ignored because there was nothing on the record to prove their wishes. I remember the Terri Schavio case extremely well, and find what is permitted by the Texas 10 Day rule absolutely terrifying. I have also worked in the Analytics field for almost 20 years, with much of that time working with healthcare providers from clinical applications to the business side of things. So I’ve seen a number of cases there where I had to wonder if the patient’s wishes were correctly carried out. On top of that, I was born with bad orthopaedic defects, and between that and some other issues, I have had surgery 15 times in my 44 years on this earth. I don’t ever want to put my loved ones in the position of making the difficult decision of making a tough choice if something bad happens and there is grey area in the situation. I encourage others to consider the same. I’ve always provided a Living Will, my Adv. Directives, and my wishes around organ donation, when I change/add new providers, or will be going through an elective procedure. However, I’ve always wondered if those caring for me will find this information if the unexpected happens due to an accident or other situation. Will they even think to contact those I have designated if I am alone and something happened? So again, something like this is brilliant! For some reason, I had assumed it is something providers can opt to add their IT/IS applications or integrate into their processes. Now I understand what you offer is its own practice.

[@chrisb1975]

I heard Dr. M say that you can bill for the services for this. Can I assume that this means my insurance might cover this? Also, other than the website, do you have any marketing info in PDF (or other) form that I could share with my company’s HR department? A few times a year, they will provide info or do online presentations about unique services and programs that are covered via our benefits. I think this would make a great thing to present and promote with my colleagues since I work in a business where most of our workforce travels 90% of the time.

[@gustavswart4649]

That is amazing!!

[@jasminaalm]

I have MBC, I'm so relieved to have a POLST .

[@grendelum]

1:02 _”...para-snorkeling...”_ 😂🤣😂🤣

[@kelly1827]

LOL re: stereotype of ED docs as adrenaline junkies. One ED doc I worked with was a professional X Games skateboarder before he settled down into medical school.

[@Sherbieable]

Don’t name your girlfriend and fail to tell her. Have lots of stories about poorly done advance directives. Get social workers trained!

[@ferdinandomirarchi5539]

Training is available through Your Voice Directives

[@aubralewis1458]

I just had this convo with my ex. Sign me up!

[@grendelum]

I can’t be first... I’d be happy with 42nd tho...

[@walterbortz5497]

I am a practicing Hospitalist and to date have not witnessed any situation in which a patient was under treated. It is a false narrative for those who practice on the frontline. Overtreatment in these situations is the standard of care in America.

[@ferdinandomirarchi5539]

Then quite frankly and respectably -you are not a practicing hospitalist. This is a nation wide suppressed patient safety issue supported by data and multiple Investigators. Look and you will see.