Advance Directives

     A verbal or written instruction plan in advance of incapacitating illness or injury which ensures that the resident's wishes about treatment will be followed for a short or long period of time. This includes but is not limited to a health care proxy, an order not to resuscitate in the resident's medical record and a living will.

Cardiopulmonary Resuscitation and DNR Orders                  

    Cardiopulmonary resuscitation (CPR) is a technique for reviving victims of “sudden death” that was developed during the 1960’s.When a person’s breathing and/or heart stops,another person breathes into the patient’s mouth and vigorously presses on the chest to compress the heart.CPR saves many lives each year.

  

CPR was anticipated to be useful primarily for victims of heart attacks and other emergencies such as drowning.But it has become the accepted method of treating anyone in a hospital or nursing home whose heart has stopped, unless otherwise specified.

  

Studies have shown that there are certain groups of patients who will benefit little from CPR.  These include people with diseases of multiple organ systems and those who are terminally ill.  It also includes the frail elderly, especially those who are not functioning independently and those who have dementia.Clearly,most nursing home residents fall into these groups.

  

In fact, research shows that the chance of a frail nursing home resident surviving CPR is close to zero.On top of this, CPR has significant burdens associated with it, including the possibilities of broken ribs and punctured lungs, further brain damage and the need for long-term ventilator (breathing machine) use.

  

The way to prevent this aggressive and largely ineffective (in our population) procedure from being performed on a nursing home resident is the issuing of a DNR, or “Do Not Resuscitate”, order by the  physician.The resident, or in certain cases an appropriate surrogate, may request the order.

  

           It is important to understand that a DNR order does not change any other aspect of the resident’s care; it does not mean “giving up” or withholding care.  Feeding, touching, antibiotics, other medications and treatments, and all other aspects of tending to the resident’s needs continue as before.  In addition, a DNR order may be revoked at any time by the person who  requested it. 

  

           We do not bring up this issue because we wish to limit care.  What we wish is to   contribute to the comfort and dignity of those of our residents who have reached the last part of their life, and to make this a time not of inappropriate burdens, but one of solace and meaning.

  

Many of these ideas appear and are further discussed in Hank Dunn’s Hard Choices For Loving People, Third Edition, A&A Publishers.   

  

Key Points

 

      CPR saves many victims of heart attacks and other emergencies.

 

      Frail, chronically ill people with many medical conditions are much less likely to respond to CPR.

 

      The chance of a frail nursing home resident surviving CPR is close to zero.

 

      DNR orders prevent the use of CPR where it is likely to do more harm than good.

 

      DNR orders do not limit care in any other way.