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Dnr b 240 2014-2019 form

but welcome to another minecraft 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 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 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 Music