What if you woke up tomorrow and learned that your grandmother had been kidnapped overnight by a couple of strangers, thrown in a white van, and taken to a distant warehouse where she spent the subsequent forty-five minutes being tortured before finally succumbing to her death?
Where she was repeatedly beaten in the chest, where a tube was shoved down her throat, where she was tasered with high voltage, where a metal drill was bored into her leg, where she was stabbed multiple times in the neck, arms, and groin?
As far-fetched as this scenario may seem, these theatrics are played out every day in the United States and around the world. Every year a third of a million people are transported to hospitals via ambulance for cardiac arrest. Usually, the chest compressions are initiated in the field. Either an intravenous line is started by the paramedics, often in the antecubital fossa of the elbow, or if there is nowhere to insert an IV, an intraosseous line is drilled into the proximal tibia in the leg. If the patient is in ventricular fibrillation or pulseless ventricular tachycardia, they are electrically shocked at 200 joules. If the patient has good anatomy and is transported by an experienced paramedic, they are endotracheally intubated and given oxygen via a bag valve mask.
Once the patient reaches the hospital, the physician, nurses, and technicians will take over the resuscitation. The patient will often be given a cocktail of medications (e.g., epinephrine, atropine, bicarbonate, calcium gluconate, vasopressin, lidocaine, and/or amiodarone), none of which has ever been shown to improve clinical outcomes in cardiac arrest.
Despite all the best efforts and actions performed in the field by the paramedics — or in the emergency department by technicians, the nursing staff, and physicians — over 95 percent of patients presenting in cardiac arrest will die. The majority of the remaining few who survive will end up being transferred to rehab facilities or nursing homes, some of the time in a permanent vegetative state. Within a few months, most of these survivors will end up dying of horrible infections like pneumonia, urine infections, or sepsis.
Does that sound like the way your grandmother wants to live out the remaining hours of her life?
The good news is that having a very simple conversation about end-of-life care can spare your loved ones from this scenario. In doing so, you can find out what their expectations, goals, and wishes are — if and when they’re ever in this situation. Some elderly family members may want every drastic measure taken to revive them despite the odds. But given the low likelihood of survival, most of them would likely choose to go peacefully.
What we as emergency physicians are advocating is for everyone to have this simple conversation with their family members. It should be done early, while they’re healthy, and thoroughly, giving them all options they can take prior to succumbing to cardiac arrest.
If they decide they would not like to be taken to a hospital under any circumstances or revived, then the three following actions should be taken:
Fill out a DNR (Do Not Resuscitate) form. They are free, quick, and serve as orders that your physician or any medical professional must follow. Under the Patient Self-Determination Act of 1991, hospitals are mandated to honor an individual’s health care decisions, including issues dealing with end-of-life care.
Make sure your family member tells all her friends, colleagues, or anyone with whom she interacts (i.e., anyone who might be in a position to call an ambulance) about her wishes.
In case nobody is around to make sure her wishes are fulfilled, advise her to get some kind of marker on her body to help medical personnel recognize and honor her wishes. There are a wide variety of options, including commercial bracelets or necklaces with the “DNR” logo.
We do not mean to denigrate end of life care or the services provided by paramedics, technicians, nurses, and doctors. We are emergency physicians and are proud to provide life-saving treatment to anyone who presents to the ER. Our greatest challenge as emergency physicians is to make timely decisions with very little information. We never know what kind of condition the patient was in before being brought into the ER by the ambulance. Our mindset is always to do everything possible during cardiac arrest situations, but we are well aware that this may not be the best strategy for many of our patients. In the elderly, in particular, we may be doing more harm than good. When the chest is being compressed, and oxygen is being supplemented, the patient may theoretically be feeling every procedure being performed on her: the pounding at her chest, the sharp needles poking her body, the electrical shock delivered at her heart.
This may not be the kind of care elderly parents and grandparents want. If you’d like to learn more, we refer you to arguably the best two books written on the topic: How We Die: Reflections on Life’s Final Chapter by Sherwin B. Nuland and Being Mortal: Medicine and What Matters in the End by Atul Gawande.
Whether you’re a physician or not, we all need to advocate for earlier and more thorough discussions regarding options for end-of-life care. We need to be honest with elderly loved ones when educating them about the efficacy of CPR and cardiac resuscitation. Above all, we need to consider their values and honor their last wishes.
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