Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Wednesday, May 07, 2008

A Proposal: NHP = DNR

Think for a moment what the world would look like if everyone admitted to a nursing home was immediately considered a DNR (or, perhaps more acceptably, "AND" as in "Allow Natural Death.") What if the whole concept of Hospice was applied to the nursing home setting? Comfort care only; living life to its fullest, each day. No invasive medical interventions except to relieve suffering.

It would solve a lot of problems.

No more fishing through mounds of paperwork from the nursing home in the ER trying to determine a patient's code status; hell, if they're all DNR, why send them over in the first place? How much of a dent might be made in ER overcrowding by eliminating the nursing home traffic altogether?

Sure, families may balk at the idea of "nursing home as a death sentence," but it might also provide that extra incentive to keep caring for the elderly at home until it's clear that they are in the last stages of life. Certainly with the rise of assisted living facilities, there shouldn't be any problem applying Hospice principles to the final stage of care in the nursing home portion of the facility.

There's no down side here. All I'm talking about is an injection of honesty and realism into our national discourse about the end of life. People die eventually; nursing homes are frequently their last "home." Why not admit it and let death come with peace and dignity, instead of the medicalized nightmare that all too frequently ensues from our refusal to address the issue.


At Wed May 07, 07:10:00 AM, Blogger MedStudentGod (MSG) said...

Spot on thinking. I'm appalled to see the amount of effort put into maintaining someone's "life" for a few more days just because family members can't let go.

At Wed May 07, 09:14:00 AM, Blogger rlbates said...

I like this concept. Could you get your patients and families to agree to this?

At Wed May 07, 09:55:00 AM, Blogger Angry Professor said...

Question: Is there a difference between a "nursing home" and a "rehabilitation center"? I worked in a nursing home for many years, and among the demented and hypertonic lived two young men (one in his twenties and one in his forties), both of whom had spinal cord/closed head injuries. There was also an older man with an undiagnosed mental illness, perfectly charming but so institutionalized he refused to leave the nursing facility for other more appropriate options. Perhaps the distinction between these different sorts of living arrangements is clearer now than it was in the '80s?

I know that after I left the nursing home and started graduate school, the younger man moved to a long-term rehab center and the older man to an assisted living arrangement.

At Wed May 07, 12:45:00 PM, Anonymous Anonymous said...

There are LOTS of people who fall into a gray area between being able to be kept at home and needing to stop all treatment. Dementia is one, and there are lots of others--like somebody who is on a trach and can't suction himself. SOMEONE needs to manage these people for their own health and safety (and sometimes the sake of others' safety), and often families can't sacrifice the wages of a member to quit a job and stay home. Not all families have somebody who is able or WILLING to provide the care, either, finances notwithstanding. Not everyone is cut out to be a home health provider.

Families quickly find out that not only can the person live for a long time in their condition, BUT insurance doesn't cover in-home care AND the cost of the care if you try to pay out of pocket is prohibitive. PBS just had a special about 3 families' eldercare situations. One woman said she essentially runs a 1-bed nursing home for her mother--at an annual cost of $250K for the services she pays for (and granted, they paid for everything, including a nutritionist to come to the house). That's a lot of money to front. I suppose it would be one thing if you knew it would only be for a few months in a terminal cancer scenario. But when it can go on for years...nursing homes serve a purpose.

I also think that if you kept the person at home and suspended treatments, you would be liable for elder-abuse. How bizarre to think of sending them someplace that is paid to do the same thing.

The whole issue makes me want to not live to a time when I am infirm.

At Wed May 07, 10:35:00 PM, Blogger jmb said...

Well that's what I did with my friend who had advanced Alzheimer's Disease and whose care I oversaw. Some months ago we (his physician and I)lowered his level of care from III (transfer to acute care for treatment) to II which meant oral medications only and make comfortable. He was unwell for a few days, fell into a coma and died at 84 two days later with no discomfort at any time. The comfort care was excellent in this extended care facility. The decision about DNR and no heroic measures was taken several years previously.

Maybe things are easier in Canada, medical personnel are not afraid of being sued.

At Thu May 08, 07:07:00 AM, Blogger Christian Sinclair said...

Hey #1D, what got you onto this futility thread lately? You are coming up with some interesting ideas with some compelling arguments.

As far as patients in nursing homes for rehab, a DNaR* by default could always be changed to full code. Often times people with advanced directives may think they are DNaR, but they don't have the official DNaR order. A new thought to cross these barriers is a POLST form (Physician's Order for Life-Sustaining Treatment). It is becoming law in a few states and can make these difficult situations (especially in a nursing home) a little more clear.

*DNaR = Do not attempt resuscitation. Saying 'Do not Resuscitate' automatically implies that you will successfully resuscitate if you are full code, which many in the health care profession know not to be true. But I am afraid this more true description will unlikely catch on.

At Thu May 08, 03:32:00 PM, Blogger The Tundra PA said...

Here, Here, Dinosaur! Excellent ideas, well said. Futile care is never what the patient wants.

At Thu May 08, 07:32:00 PM, Blogger janemariemd said...

We have the POLST in WA state and it is printed on electric green paper, to be posted on a refrigerator so the paramedics won't resuscitate someone who has one that says DNR (otherwise they WILL, even if a family member right there tells them not to).

I like the POLST because it has separate sections for 1) other intensive treatments (ie telemetry), 2) antibiotics, 3) feeding tubes. I like this because the resuscitation decision is just one of several that ought to be made. It is pretty routine to have the form completed on NH admission in my area. I agree with the dinosaur's comments, but would go further and suggest that many NH residents ought not be transferred to a hospital under most circumstances. The severely demented don't handle hospital stays well, so I have been trying to let families know I try pretty hard to not transfer their loved one. We can give antibiotics at the NH and do other things to make people comfortable there.

At Sat May 10, 09:22:00 PM, Blogger Doctor David said...

I think I'm coming from a different place, because I'm a pediatrician, but I totally agree with the comfort care/allow natural death approach to the end of a patient's life. As an oncologist, I face this with my patients all too often. This week, in fact, I was finally able to convince the family of a teenager dying of recurrent, refractory sarcoma that intubating her and resuscitating her might not be in her best interest. The order said both DNR and allow natural death. In the end, it was what the child and her parents wanted, hard as it was to accept.


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