when to complete a DNR?

[Tybee]

i had to fact check myself as I could recall talking with my doctor recently about this.

https://pubmed.ncbi.nlm.nih.gov/2751179/

Wow, and by the way, hate the title (I'm 70): "Outcomes of cardiopulmonary resuscitation in the elderly

Patients: Five hundred and three consecutive patients aged 70 and over who received cardiopulmonary resuscitation.Measurements and main results: Of 503 patients, 112 (22%) survived initially but only 19 (3.8%) survived to hospital discharge. The poorest outcomes were for patients with unwitnessed arrests (1 of 116 survived), terminal arrhythmias such as asystole and electromechanical dissociation (1 of 237 survived), and patients with cardiopulmonary resuscitation lasting more than 15 minutes (1 of 360 survived). Only 2 (0.8%; CI, 0.0% to 2.0%) of 244 patients with out-of-hospital cardiopulmonary arrests left the hospital alive. "

Nonetheless, we've talked it over and decided to not fill out the DNR at this time, and reconsider later.

[rosarugosa]

I feel like these forms need to be reviewed and potentially updated often in our age group. I recently completed a MOLST form for myself, after some discussion with my sister. We agreed that my wishes at age 68 may very well be different at age 78, and also depending on my mental and physical health at that point in time.

[bae]

i had to fact check myself as I could recall talking with my doctor recently about this.

https://pubmed.ncbi.nlm.nih.gov/2751179/

Note that the actual situation, for out-of-hospital events, is considerably more nuanced than the numbers in that report.

As I mentioned above, my remote community has the highest survival rate in the country for those sorts of events. But not because we are lucky.

We have:

- a large portion of the civilian population trained well in CPR, and how to do team-CPR
- our fire/rescue/ems services here are world-leading in delivering high-performance CPR, to the point where we are often used as the testing ground for new protocols
- our 911-dispatch system is trained and practiced at delivering "CPR over the phone" - teaching a civilian over the phone how to do good CPR in real-time once they've called 911
- we have an incredible density of AEDs in the community
- we have a well-oiled system to air-evac patients to a higher level of care once they are stabilized enough to be flown. We can often get you to definite care *faster* if you drop on the street here, than if you did so in downtown Seattle.

It would be useful for you perhaps to investigate how your own community deals with these situations.

[Tybee]

Note that the actual situation, for out-of-hospital events, is considerably more nuanced than the numbers in that report.

As I mentioned above, my remote community has the highest survival rate in the country for those sorts of events. But not because we are lucky.

We have:

- a large portion of the civilian population trained well in CPR, and how to do team-CPR
- our fire/rescue/ems services here are world-leading in delivering high-performance CPR, to the point where we are often used as the testing ground for new protocols
- our 911-dispatch system is trained and practiced at delivering "CPR over the phone" - teaching a civilian over the phone how to do good CPR in real-time once they've called 911
- we have an incredible density of AEDs in the community
- we have a well-oiled system to air-evac patients to a higher level of care once they are stabilized enough to be flown. We can often get you to definite care *faster* if you drop on the street here, than if you did so in downtown Seattle.

It would be useful for you perhaps to investigate how your own community deals with these situations.

These are amazing facts! I particularly like the training of the 911 operators, such a brilliant idea.

[bae]

These are amazing facts! I particularly like the training of the 911 operators, such a brilliant idea.

911 operators are often the first First Responder :-). I've spent days over there watching their operations and training, it is a very cool profession.

Ours have saved lives just by walking people through what to do over the phone, before my Fire/Rescue agency even shows up on-site.

Much respect for them!!!

[pinkytoe]

My niece is a 911 operator. Loves her job but says there are long hours of boredom mixed with high stress situations where the caller is dependent on her instructions and calming efforts.

[Rogar]

It would be useful for you perhaps to investigate how your own community deals with these situations.

Some years ago I was in a super market in a close by town and a fellow dropped onto the floor and was unconscious. A small crowd gathered standing around him trying to rouse him by "are you OK", but no one had any idea what to do. It was my inspiration to get certified in CPR, although the certification has lapsed I have a very general idea of things. Eventually the man roused and by that time first response was on the scene to take care of things. I don't think I would count on my community to have the degree of training as yours, but don't really know for sure.

I've talked about this with my sort of reliable doctor and he has suggested reviewing my DNR every couple of years and I may want to back off on things if my health changes and maybe when I get to 75. It's something I'm stiull not sure about and will continue to look at it as time progresses. I don't claim to have the right answer.

https://www.npr.org/sections/health-...n-enduring-cpr

The traumatic nature of CPR may be why as many as half of patients who survive wish they hadn't received it, even though they lived.

But the true odds are grim. In 2010 a review of 79 studies, involving almost 150,000 patients, found that the overall rate of survival from out-of-hospital cardiac arrest had barely changed in thirty years. It was 7.6%.
Bystander-initiated CPR may increase those odds to 10%. Survival after CPR for in-hospital cardiac arrest is slightly better, but still only about 17%. The numbers get even worse with age. A study in Sweden found that survival after out-of-hospital CPR dropped from 6.7% for patients in their 70s to just 2.4% for those over 90. Chronic illness matters too. One study found that less than 2% of patients with cancer or heart, lung, or liver disease were resuscitated with CPR and survived for six months.

https://www.griswoldcare.com/blog/cpr-on-elderly-long-term-side-effects-of-resuscitation/#:~:text=This%20information%20does%20not%20constit ute%20medical%20advice,*%2012%25%20or%20lower%20af ter%20age%2070

A main factor in the success rate is how quickly CPR is performed after cardiac arrest. Other factors like the reason for the cardiac or respiratory arrest and other underlying health conditions like cancer or other diseases also contribute to the likelihood of survival after CPR.
Quality of Life After CPR

The main concern when choosing whether or not to perform CPR on elderly patients is the quality of life after resuscitation. CPR can have long-term side effects, and many patients who survive CPR wish they had not had it. Some of the risks of CPR include:

• Broken chest bones. Smaller people or people with more fragile bones – such as the elderly – are at a high risk of broken ribs or a broken sternum as a result of CPR. Studies show 81% of people who receive CPR have broken ribs afterward.
  
• Neurological damage. When the heart stops, blood stops flowing to the brain, causing the brain to be deprived of oxygen. Brain damage begins to occur four to six minutes after the brain stops receiving oxygen. In general, around one-third of the people that survive CPR end up with neurological problems due to lack of oxygen to the brain.
  
• Vomiting. It is not uncommon for vomiting to occur during chest compressions. This can lead to stomach contents aspirating into the lungs, which can lead to infections like pneumonia.
  
• Other complications can arise, like organ damage or internal bleeding.

[bae]

Our experience in my community has been quite different, as detailed above.