As you probably know, doctors love DNI/DNRs and everything that clearly prescribes what to do. So the first thing we try to establish with an elderly seriously sick patient is whether intensive care or resuscitation is really an option.
Yet a DNI/DNR label might signify many things to the team:
- In an emergency, don’t tube, don’t CPR
- Avoid advanced and invasive treatments, such as operations for intracerebral hematoma
- If in doubt, don’t try to cure the patient, prefer comfort measures in a palliative setting.
- The prognosis is judged to be bad, either mortality-wise or with respect to quality of life.
Although meaning 1 is usually what is intended and agreed upon, meanings 2 and 4 are often used as reasons, and meaning 2 is sometimes implied, even if – as in our house – the difference is made explicit even by SOPs.
Concerning prognosis, we know that
- Neurological emergencies are very hard to prognosticate in the first 24, even 72 hours
- Even epidemiological data is scarce – the best evidence exists for mortality of intracerebral hemorrhage (e.g. ICH score) and proximal occluded cerebral arteries; quality of life is a different beast altogether.
- Stating a prognosis early leads to self-fulfilling prophecies
Our discussion of the subject does not lead to clear procedural standards, but it sensitizes…
- An excellent 2009 article about Nihilism in neurological emergencies
- A 2011 article about futility and it’s modern meanings