Empowering End-of-Life Choices: DNR/DNI Mandate

People have trouble accepting and coping with death and dying. Having a discussion regarding the end of life wishes is a conversation most people would rather avoid. Family members and loved ones should not have to carry the burden of making decisions concerning life or death. DNR/DNI orders should be mandatory for everyone from birth to old age, regardless of their bill of health.

There are three options when it comes to a person's code status - full code, DNR, or DNI.

In the event someone goes into cardiac or respiratory arrest, medical staff will step in and begin chest compressions (or CPR) and deliver electric shocks to your heart (defibrillator). If the airway is obstructed in any way, a tube will be inserted down your throat which connects to a machine known as a ventilator to help you breathe - this is also called intubation. When a patient agrees to have these things done, they are considered a full code.

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DNR stands for "do not resuscitate." This gives medical staff permission to intubate a patient if they're in respiratory arrest, but no cardiac resuscitation will occur, even if the patient is in cardiac arrest. DNI is the opposite of DNR, it stands for "do not intubate." If the heart stops, medical professionals will begin chest compressions, but won't insert any tubes down the patient's throat during the respiratory arrest. Patients have the option to be a DNR, DNI, or both, DNR/DNI, which means no cardiac or respiratory measures will be taken to save your life.

Typically, when someone either has a routine doctor's office appointment or an emergency room visit, the medical staff will ask you about your code status. A lot of people don't know the answer to this question, which is okay. A medical professional may ask, "In an emergency, would you like for us to do everything we can, including CPR, inserting a breathing tube, and/or delivering electric shocks to the heart to try to save your life?" If you answer yes, you would be considered a full code.

There are legal documents people may sometimes use to indicate how they want to be taken care of in the event of a medical emergency. An advance directive is a written statement of someone's wishes regarding medical treatment in the event they're unable to communicate these wishes to a doctor. A health care proxy is a document in which someone you trust is appointed to make medical decisions on your behalf when you're unable to. Both options are beneficial when a patient is either unconscious or in a coma and a medical decision must be made. In certain states such as New York, there's a MOLST form. MOLST stands for medical orders for life-sustaining treatment. This form contains more specific guidelines pertaining to life-sustaining medical treatment that the patient can decide if they want to accept or avoid certain treatment options. A physician or nurse practitioner must read and sign a MOLST form and cannot convey the patient to change the course of treatment if they don't agree. An advantage to the MOLST is it takes effect as soon as a physician signs it. A health care proxy or advance directives only apply when a patient is incapable of making medical decisions, whereas a MOLST always applies, no matter the patent's capacity.

When a person is ill, medical staff and family want them to be as comfortable as possible. Palliative care can begin at the time of diagnosis, as well when treatment starts. Hospice care usually takes place more towards the end of life, when all treatments stop for illness and there's no chance for survival.

Families have a hard time letting go of someone they love. Most people don't consider their end of life wishes, thinking they have plenty of time in their lifetime to decide. Accidents happen, and usually, the families have no idea what to do in a life or death situation. Say you're involved in a serious car accident; would your loved ones know your wishes? Would you want to live on a ventilator, as a paraplegic, or in a vegetative state? How important is your quality of life when it's possible it may boil down to this? Consider the burden of your family having to provide care for you around the clock. Having a DNR/DNI order in place could prevent family and friends from arguing over what the outcome should be.

Children want to hold on to their parents, and parents want to hold on to their children. Denial kicks in and the hope for recovery clouds your judgment. Accepting that your mother, father, or child is brain dead and will never be "normal" again is a hard pill to swallow. Life support is any combination of machines and medications that keep a person's body alive once their organs begin to fail. Most people depend on this, thinking their loved one is "somewhere in there" when usually all brain activity or organ function has stopped. Life support can be costly, around $4,000 a day. Insurance companies will usually cover the first 30 days, then it's the family's responsibility to either take care of the expense or turn off the machines.

In the same facility, there's a dementia unit. Dementia is a group of diseases (for example, Alzheimer's), that affects a person's ability to perform daily life activities. The most common is memory loss. The life expectancy for dementia is about ten years after the initial diagnosis. Any infection, like pneumonia, can speed up the process and a person's health can decline, fast. I learned that if the patient is transferred to the dementia unit, they automatically become a DNR/DNI. Social work usually discusses this with the family, they must agree and sign the order. When a medical emergency or code blue is announced on this unit, staff doesn't rush and run like they do on television. There's no crash cart involved, no CPR, staff stand around the patient until they stop breathing. The time of death is announced, the nursing supervisor is notified, and the family is contacted. Family can perform post-mortem care and arrangements are made with a funeral home to pick up the body. In situations like this, who makes the decision that a dementia patient's life isn't worth saving? How do we determine whose life matters more? We'll stand around and literally watch someone die but will take extreme measures to save a brain-dead patient. Where's the fairness in that? We as humans should not determine which lives are worth saving.

Having a plan in place can save the people you love some heartache. Making medical decisions when your emotional state is compromised is almost impossible. Sometimes these decisions must be made quickly and can determine life or death. A simple document can indicate what needs to be done in order to save a life. Quality of life should not be the decision of anyone but the patient. Under what circumstances do we decide whose life is worth saving?