Advance Directives- Pre-Hospital DNR, or AND

The idea around decisions or orders to Allow Natural Death (AND), or Do Not Resuscitate (DNR) is to address your preferences or personal wishes in the event of a sudden and immediately life-threatening loss of heartbeat and/or ability to breathe.

In previous posts, we discussed directives you can make which speak to your wishes on matters affecting your medical care.

This post specifically discusses sudden, unexpected and potentially immediately fatal events occurring outside the setting of a hospital or ER, and your wishes in such an event. More particularly, this pertains to a sudden loss of heartbeat and ability to breathe such as might occur in a massive heart attack.

This may be ultimately expected in a terminal illness such as advanced cancer, or may be entirely unexpected.

Doctors generally ask about your preferences since we do not wish to withhold care from you that you want, but we also do not wish to perform heroic or even desperate procedures on you that you actually do not want.

Certainly, you should realize that a decision by you to allow a natural death or not to resuscitate does not affect your care in other matters such as your cancer, pneumonia or hip fracture. As our nursing colleagues rightly point out, "no resuscitation does not mean no care"!

Something to be mindful of in your decision-making is what is occurring during a loss of breathing and pulse and during CPR.

A sudden loss of breathing and pulse can occur for a variety of reasons, but while it is occurring, there is a significant loss of oxygen supply and blood flow to your brain. CPR is an attempt to maintain circulation of blood to the brain while awaiting definitive attempts to restore normal heart rhythm by delivering an electrical shock. This is known as defibrillation (or "shock paddles", as seen on TV). Medicines given if this occurs in a hospital are largely given in order to maximize blood flow to the brain. It is ultimately timely defibrillation that can restore normal heart rhythm with intact brain function.

Note the emphasis on the intact brain function part.

The tricky part here is that your brain can only go for 5 minutes without good blood supply before permanent brain damage starts to occur. Past this limit, the longer the duration of sub-optimal blood flow the more extensive the damage. For a worst-case scenario, think Terri Schiavo.

Even in the best of circumstances where this occurs in a hospital, the odds of going home alive and with an intact brain are about 15%.

If this occurs outside a hospital (such as at home, a friend's house, a movie, a restaurant, etc.) the lack of immediate access to a defibrillator makes an enormous difference.

If you survive long enough to make it to an ER, and survive long enough to actually be admitted to the hospital, your odds of eventually going home alive and with an intact brain are only 2-8%. This is because your valuable 5 minute window of opportunity is already gone by the time paramedics can arrive even if someone has immediately called 911.

Once paramedics arrive, they are legally required to initiate CPR and resuscitative efforts. If, given the aforementioned discussion, you would wish for them to do so, you do not need to take any action at all.

On the other hand, if you would NOT want them to do so, you need a signed order from a doctor instructing them not to start resuscitative efforts.

This handout and sample form can be used if you feel that you would not want paramedics to start resuscitation for such an event in your home. It only requires your signature (or your caregiver's) and your doctor's signature.

(Paramedics will still come to your home and provide the usual help in all other matters! Signing this does not mean that they will not come to your home, or help you if you have fallen down or have a medical problem.)

Advance Directives- POLST

In 2009, a new sort of advance directive became available. It is called Physician Orders for Life-Sustaining Treatment (POLST). It is not meant to replace an Advance Directive for Health Care, but rather to amplify on it in a clear and easily read manner. Also, it can be used even if there is no formal Advance Directive.

Additionally, the POLST form takes the form of a physician order and does not require notarization or witness co-signatures as does the Advance Directive. It addresses your wishes around heroic resuscitation or cardio-pulmonary resuscitation (CPR), as well as your preferences in terms of how intense or aggressive you wish your medical care to be in the event of a serious medical problem.

This is a very helpful list of frequently asked questions from the California Hospice Foundation.

This .pdf document is the actual POLST form itself for your use.

Advance Directives- An Introduction

Advance Directives are important legal documents, but are sometimes misunderstood. Generally speaking, advance directives designate another person or persons to make decisions or take actions on your behalf should you be unable to do so for yourself. They can also be designed to state your own wishes and preferences.

Many people have such directives around legal and/or financial matters. For example, they may have a will or a living trust or they may have a document authorizing their spouse to gain access to financial accounts or pay bills or sell assets if they were to become unable to do so themselves or jointly.

Advance Directives for Medical Care (so-called "Living Wills") make your wishes known about medical care and designate people to make medical decisions for you if you become unable to state them for yourself. For example, you will typically be asked to state a preference around organ donation and around prolonging life in the event that you are in a coma or persistent vegetative state ("brain dead") or some terminally ill condition.

Please be aware that your wishes around artificially prolonging your life only become applicable when you are already brain dead or in a coma or terminal condition. Advance Directives generally do not address your preferences or wishes around scenarios that could lead up to being terminally ill or brain dead.

For example, you may have strong feelings about the roles of interventions or procedures such as dialysis or emergency brain surgery in dire emergencies where you are already so sick that cannot discuss them for yourself. It is okay to add these wishes to your Advance Directive.

Advance Directives allow extra space for the addition of any further statements that you may care to make. In California, they do not require an attorney to draft. They simply require your signature and either a notary public or the signatures of two persons who know who you are.

However, you may wish to enlist the aid of an attorney if such a directive seems complicated or unclear.

This site has state-specific free downloads of Advance Directive forms.

Five Wishes (produced by the non-profit Aging With Dignity) is an advance directive that more fully addresses your feelings around comfort and is a bit more specific around examples of life-sustaining interventions or procedures and allows you to address them as you see fit. The document costs $5, but can be previewed for free as a .pdf document.

This form from the Attorney General's office of the State of California is also freely available.

We also have a handout on this subject and sample forms from the California Hospital Association for your use. Feel free to ask for one next time you are in the office!