DNI/DNR and what it means

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:

  1. In an emergency, don’t tube, don’t CPR
  2. Avoid advanced and invasive treatments, such as operations for intracerebral hematoma
  3. If in doubt, don’t try to cure the patient, prefer comfort measures in a palliative setting.
  4. 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…



The nocebo effect

I have become quite infatuated with hypnosis lately, having done an introductory course. This led to renewed interest into the psychology of everyday medical communication and thus I arrived at the topic of the nocebo effect. There is a lot of literature about the subject, but not very many actually delve into the details.

So here is my short description of the theory.

  • Patients in hospitals (and in particular the ER, OR and ICU) are scared and confused, which leads to high suggestibility.
  • Highly suggestible people can take in every word you utter, so you have to be careful what you say.
  • Most of our daily smalltalky utterances influence negatively.
  • Highly relevant communication such as informed consent, speaking with relatives, is particularly prone to such effects. So we should precisely filter what we tell patients, e.g. about medication side effects to spare them the nocebo side effects. In how far this is ethical, is not too clear.

This might all seem pretty obvious, but the consequences are immense.

  • Our soothing remarks like “just a wee sting here”, “some cold” and so forth mainly serve to soothe ourselves, the will hurt the patient literally. So the best thing is to dump them.
  • If you really want to soothe a patient for a painful procedure, use techniques of everyday hypnosis, like focusing attention on something nice, using narratives and engage the mind in doing things actively instead of hoping for passive tolerance.
  • Our empathic questions about nausea and headache in situations where patients could but should not have these symptoms can really provoke them. It is way better to use a positive formulation, such as “Is there anything we can do to make you feel even better?” [Of course, if you need to know about symptoms for your differential diagnosis, then you still have to ask for them, but remember that in a properly taken history, the patient is supposed to volunteer all relevant information and the review of pertinent symptoms asked in quick succession after the opening phase of the interview should basically all be answered in the negative.]
  • Telling patients about side effects of drugs and procedures should be done carefully, perhaps asking the patient if he or she would be open to forgo a detailed listing if that helps them. Also always use the positive numbers instead of the negative ones and be sure to use the proper modality (90% do fine with LP, a few might get headache). [But beware, people who tend to want to make a choice each and everywhere might react differently to this use of modality, so you have to fine-tune your statement, adapting to personality styles.]

Obviously, I am not an expert on this subject, but my talk should help to interest you in the field. Here are some introductory references.

Decompressive craniectomy as an ethical problem

The world has not become simpler since Destiny-II has come out. But this only serves to illustrate that the underlying questions as to what makes life acceptable, what constitutes a life worth spending 3 weeks in ICU hell, 1-3 years in depression and predementia cognitive impairment, cannot easily be resolved. A complex topic such as decompressive craniectomy for malignant MCA stroke cannot be explained in two sentences. So we will try to lead a fruitful ethical discussion in the style of PBL – let us see what becomes of it.

Here are some important references:

Medical futility, DNI and DNR

Don’t expect very much input from me, but we used our time last friday to discuss the way we reach the conclusion that a stroke in an elderly patient perhaps should be treated not too aggressively. More clearly, how do we determine, whether the patient is going to die. 

This is a sensitive topic and it concerns our basic ethical, religious and moral experience. It requires some facts (but not many) and a lot of discussion, so this is, what we tried to do. I think, that the style of discussion coaching that Problem-based learning supplies, might be the best environment to reach such conclusions, and the discussion should be interdisciplinary, including physiotherapists, SLTs, nurses, doctors, relatives and so on. But in practice such ethical conferences are only scheduled if the core ethical problem is really hard (or hard to understand). Your straightforward 87yo big MCA stroke is somehow “easier” (please don’t understand this the wrong way) – also we could not call an ethics board for every DNI order.

My solution is to make the discussions more open, use rounds and pre/post-round-coffee-time to discuss DNI/DNR orders and other therapeutic limitations. And this requires some experience…

The Tuskeegee study of untreated Syphilis

Latent late Syphilis is something we rarely encounter, because we only treat neurological patients and every neuro patient has a problem, which in turn can be attributed to some form of Syphilis, so that when we test him for Syphilis he has an active Neurosyphilis (this is regardless of his CSF status).

This is why we know practically nothing about the form of Syphilis that was covered by the infamous Tuskeegee study. We discuss the relevant core facts, why it raised a huge anti-racialists hype. We try to understand what happened and use the information of this excellent article to excuse the Syphilologists of the time.

End-of-life care on the ward

Since stroke care is care for very sick patients, we face this situation at least every week: to withdraw “life support” and let the patient die. So assume a patient (in our case a terminal mitochondriopathy patient with resistant status epilepticus) that eyeryone (including – by advance directive – the patient) has agreed will, may and should die. We discuss the practical aspects of care in these end-of-life situations.

Some certain goals in this terminal phase of care are:

  • The patient should not suffer (too much) hunger, thirst, pain, dyspnea
  • The relatives should not suffer (too much)
  • The team should not suffer (too much)
  • It should not take too long (this pertains to all three previous goals)
  • Religious and personal final requests should be met.

There is some controversy about whether the patient should be kept from fear, should remember the experience (or get some benzos to forget), should be allowed to be awake at all.

How do patients actually die? Of course, that depends, but in Neurology, most of them aspirate continuously until pneumonia takes over and then (through infection) some cardiovascular complication does it (like pulmonary embolism, arrhythmia, CHF decompensation). If you want to let this take it’s course, you will reduce your respiratory care, not suctioning to often, giving Morphine and Oxygen ad libitum. Take your time to increase the MSI dose until the patient breathes peacefully, pupils are small and the heart rate shows that stress is under control. If anxiety is predominant add benzodiazepines. As for liquids, the problem is not dehydration (this actually promotes the dying process) but thirst and dry mouth is – so you should add mouth rinses and morphine so that thirst is under control. If the process takes longer than expected (or hoped), lack of nutrition becomes important through it’s effect on immune reaction, but hunger should not appear (again, Morphine does the trick).

You cannot hope to predict the time of death, since you never know the precise pathophysiology, so call religious services, relatives and everyone else required by the patient as early as possible. Leave room and time for all the people to be able to tend to the patient. Show up from time to time, but don’t keep them from suffering – the death of a loved one is something you cannot make a pretty experience through empathy. Tears, moans and crises are normal and should be met with empathy and professionalism.