but welcome to another MedCram lecture today we're gonna talk about something a
little different in terms of treatment we could actually talk about DNR full
code palliative care just a quick primer on those sorts of things especially in
terms of what we do in the intensive care unit but also what we do on the
floor so I think this is kind of a confusing topic for some people who are
not used to it DNR stands for do not resuscitate and of
course the do and the not are pretty clear but the resuscitate can sometimes
be a little confusing so when someone says somebody is DNR that means they
don't want to be resuscitated but what does that exactly mean and I have they
fully given consent about what it is that they want to have done well the
opposite of DNR is a term that we sometimes call full code and that comes
from the fact that when somebody in their heart stops or they stop breathing
they have something called a code blue and it's during that code blue that you
can do all sorts of things and that would be a full code what I like to do
is kind of divide it up into three different possibilities of things that
could happen and really what we ought to be doing to patients is is not saying to
them when they come in if something like this happens do you want us to do
everything because who doesn't want to have everything done what we should be
doing is we should be telling them exactly what it is that we're going to
be doing and what are the side effects of these things so patients and families
get a full informed consent so the first thing is probably the most what we call
heroic or the most invasive and that is basically cardio pulmonary resuscitation
this is where we pound on someone's chest and we do chest compressions and
you know usually you've got to go an inch and a half down to two inches of
depth to get really good chest compressions so that you can actually
pump the heart and get the blood flowing and that can cause rib fractures so CPR
and that goes along with all the things that you learn is something called
advanced cardiac life support or ACLs and then also which goes along with that
is shock so and I'm not talking about septic
shock I'm talking about all actual electric shock so all of these things
kind of go together because if you're undergoing CPR there's a chance that you
could go into a shockable rhythm so you could get shock and then you'd be giving
things like epinephrine one milligram or you'd be giving amiodarone or something
that goes along with ACLs and these are medications and so these things are
typically done together unfortunately CPR ACLs shock in terms of
in hospital cardiac arrests are usually not very effective but they do have a
high incidence of for instance breaking ribs and so patients need to be aware of
that so if someone's coming in to the hospital from a trauma and otherwise
healthy CPR ACLS shock may otherwise get them back on the road but if someone's
being admitted to the hospital after many bouts of pneumonia because of lung
cancer and they've just you know had it they don't want to have any more of this
intervention this may be something that they don't want to have done to them so
making sure that they're aware of that is important
so that's CPR ACLs in shock and they kind of go together the other thing that
can happen is something called intubation
so intubation is where we put a tube down someone's throat obviously into the
trachea they can't talk and they usually have to be sedated and we do this either
because they can't breathe for themselves or their neurological status
is bad enough so that they can't protect their airway putting someone on an ET
tube endotracheal tube is not a benign process especially when someone is
unstable we have to sedate them usually with medications and sedatives and
sometimes also paralyze them so we can intubate correctly there's a risk of
aspiration there's a risk of trauma there's a risk of hypotension of coding
all of these things could happen if we were to do intubation and there's a risk
that the ET tube could go down too far and you could have a right mainstem
bronchus intubation etc etc so those are all complications but sometimes you need
to do intubation and that's usually pretty effective at protecting that
airway the last one is probably the least invasive and that's Bayes
oppressors and please look at our video on bayes
oppressors for more information about that but these are basically medications
that we would give in septic shock to increase the blood pressure to make sure
that the map or the mean arterial pressure is greater than 65 millimeters
of mercury medications like Levophed medications like epinephrine vasopressin
neos a nephron these are the sorts of things and typically we like to put
these through central lines or if they're going through peripheral lines
we we want to make sure that they're not too concentrated and they're going
through the right peripherals because if they infiltrate they can cause some
serious tissue damage so what's the risk of vasopressors the risk of a
suppressors is is that if you give too much it could cut off circulation to the
extremities and that can cause necrosis they can cause arrhythmias you need to
put central lines in for those and so what I like to do when a patient comes
in is instead of asking them do you want us to do everything because the question
is is who wouldn't want you to do everything that you could possibly do
the reason why we're asking it is because there's significant side effects
to these very invasive procedures and we want to make sure that it's in line with
the values that the patient wants to have so be very specific I would ask the
patient if if your heart were to stop would you want us to run in there and do
chest compressions and to pump on your chest an inch to two inches to get your
heart going and pumping knowing that we could be breaking ribs and we might have
to put a chest tube in after because of a pneumothorax do you want us to be
giving you medications do you want us to be shocking you and then let them know
what the side effects of those things are and obviously let them know that the
only benefit would be to get them back where they were before their heart
stopped would you want us to put a tube down into your lungs and put you on life
support and on a ventilator where you can't talk and you have to be sedated
and this would be of course to protect your airway or to continue your
breathing would you want us to put you on medications that might require a
special type of IV access so that we could keep your blood pressure up some
patients don't want to have these things and if they don't want to have any of
these things then the term that we typically use is DNR D&I
and this DNR dni status would go on their chart and the reason why is
because you don't have time to call the family if the patient codes on the
monitor so you have to make sure that that's the case if they want any of
these things to be done so if they're actually interested in let's saying
vasopressors then the term would be a modified code and you'd make sure that
that was specified on the chart so that they would know to give vasopressors in
that situation but perhaps maybe not cpr or perhaps not ACLs so a discussion
that's good to have with patients when they come into the intensive care unit
is what I like to call the pillar talk and the pillar talk is a good
representation I believe of what happens in the intensive care unit so the first
thing that I tell them is that the patient's life is like a roof it's a
ceiling and it's being held up by pillars okay and these pillars are the
body's organ systems so for instance one organ system is the heart another organ
system might be the lungs another organ system might be the kidneys and another
organ system might be the immune system okay but these pillars are all working
in conjunction with each other and they all are being used to keep the patient's
life now what happens in the intensive care unit is usually patients are in the
intensive care unit because they have problems with one or two of these organ
systems so in other words the heart system may fall down or the lung system
may fall down and so as these pillars start to fall down more and more weight
gets put on the remaining pillars so obviously if the more pillars fall down
that's going to put more stress on the remaining pillars and the whole roof and
the whole system could come down and that's obviously equating to death and
so what we do in this situation is if we see the heart pillar fall we identify
that and we hold up that system while that heart pillar has
fallen down in this case the way we would do that would be through
vasopressors so if the cardiovascular system is not working we hold up the
roof in that area where the heart pillar used to be
if the lung pillar has fallen down we hold up that part of the roof with the
ventilator if the kidney pillar has fallen down we hold up that part of the
roof with hemodialysis and so what we're doing is these patients who are in the
intensive care unit are on life support we're holding up those portions of the
ceiling the roof if you will while the patient's pillars have fallen down and
then what we do is we wait to see if those pillars through supportive care
and regeneration of the body which obviously happens at a younger age
better than it does at an older age but if we start to see these pillars come
back up again in a way that we can then pull off the support for instance in
that situation stop dialysis if these pillars start to come up in a way that
we can pull off support for instance we in the patient off the ventilator or in
the example of the heart pillar we can get them off of vasopressors then we can
pull off support and the patient gets better the key here though is not how we
do the support of the patient obviously we want to be as careful as possible in
supporting the patient but it's really up to the patient's ability and the
vitality of that patient to bring those pillars back up okay and so what we
typically see is three different possibilities and the intensive care
unit we see the patients whose pillars are down but they come up very quickly
and we're able to get them off life support and out of the intensive care
unit and then we see patients who the pillars are falling down and despite the
fact that we're holding up the pillars additional pillars continue to fall
until finally we're just not able to hold up the roof and the whole the whole
roof comes down despite all of our support and the patient passes away in
the intensive care unit and then the third type is that we're holding up all
of these pillars here we're giving support through the ventilator through
Bay's repressors through dialysis through antibiotics for the immune
system etc etc and despite that we're kind of stuck in a holding pattern where
the pillars are not coming back up and we're
still holding the roof and then we get into discussions with the family about
how long they would want their loved one to be on these life support and you know
sometimes patients will say to their loved ones look if if I'm sick and I'm
going into the hospital you know go ahead and do everything you can for at
least you know a few days and if it looks like nothing's working and I'm
stuck on this life-support then don't leave me on life support just go ahead
and take those off if the patient's Pilar's come up really quickly and
everything's going well we just we wean off the ventilator we wean off the
vasopressors we can take the patient off dialysis we can end the antibiotics
because the immune system has now replenished itself and that's great the
patient gets stepped down to the regular floor when they're able to do their
activities of daily living they living they can go home from the hospital but
in the situation where the patient is continuing to get worse and worse and
worse and other pillars are falling despite the fact that we're holding up
and supporting the patient's life that's when I have a discussion with the family
and I bring up that discussion that we talked about before with CPR because all
of these things that we do here in the intensive care unit when we're holding
up the ceiling with vasopressors with antibiotics with the hemodialysis with
the ventilator these are very effective things very effective at holding up the
ceiling if everything's falling down and the last thing that we have left is CPR
CPR is not very effective very low survivability with in-house CPR in other
words if the heart stops it's stopping for a very good reason typically and so
when I approach the family with this information usually what they will say
is look if you've done everything you can through these very effective
measures here trying to keep the roof up through dialysis through vasopressors
through antibiotics things that are very effective and they are not able to work
and turn the patient around and we get to the point where the heart stops then
just let the heart stop and don't do the CPR and I think once you explain to them
the risks and benefits then they're more apt to not do CPR now some wanted
do CPR and we're happy to do that but that's a decision that has to be made
always before the time comes for CPR and the reason is is because when the time
for CPR comes there is no time to call family that's the decision that has to
be made before the time comes so I hope this discussion was helpful in the next
video we're going to talk about what kind of a discussion that we have with
family in the intensive care unit where we're stuck in that situation where the
patient's not getting any worse the patient's not getting any better and the
patient's been on life support for days perhaps even weeks and they don't want
to have that anymore because it's not consistent with the patient's values so
let's talk about that in the next video thanks for joining us