Intubation involves a doctor inserting a flexible plastic tube through the nose or mouth into the trachea windpipe to help with breathing. This tube is then usually connected to a ventilator machine that pushes oxygen into the lungs. Opting for a DNI can be a difficult decision to make for your loved one with a life-limiting illness..
This means that if circumstances or feelings change, the DNI can be easily removed. However, if there is a living will, it is important that the legal order is on record. Sometimes, the patient will make the choice to request a DNI in advance which will be recorded in their medical chart. This is most often the case with a terminal illness. They may instead, however, choose a DNI where they wish to avoid intubation. This decision is usually made by a patient who wishes to avoid relying on a ventilator and any complications that can sometimes occur with intubation.
While it is very rare, intubation may cause heart attacks, lung infections, strokes, and temporary mental confusion for patients diagnosed with terminal conditions. I asked him again about whether he would want to be resuscitated or intubated if needed to keep him alive. He said he would, so long as it would not mean a life permanently dependent on a machine. He walked out of the hospital two days later, knowing that he had almost died. What he did not know was that aside from his heart stopping, he'd come one step closer to death because of a lack of clarity in his code status, which easily could have resulted in us stopping our efforts to revive him.
End-of-life care is a vastly complex topic. All patients who are admitted to the hospital are asked about their code status, often by a medical intern or resident.
This choice is far from simple, and the way these questions are worded can be a major factor in a patient's choice. Some would argue that "pass peacefully" wording is only appropriate for a patient with nothing to gain from invasive measures. The conversation demands something different in a case like Mr.
R's, when a patient only needs to be intubated temporarily. Informing patients of the potential outcomes of their decision is key, yet studies suggest that medical residents mention this in less than one-third of their code discussions. I have found that when patients truly understand the likely outcomes they face, their decision often — although not always — matches what I would have recommended to them. For many, this entails opting for intubation as long as it is likely to be temporary, and avoiding chest compressions unless there is a moderate to high possibility of significant recovery.
I find expressing compassion helps, as does being straightforward about the prognosis, and offering recommendations to help guide a decision. What does that mean to you? Who else can help? Much of the criticism about how hospitalists talk about code status is that we jump into it without getting the idea of patient goals beforehand.
When we wrote the JHM paper, my colleagues and I agreed that the discussion ought to be framed around goals, and only then should we make a recommendation and come to a consensus. Saturday, November 13, Today's Hospitalist. Streamlining admission decisions. Big payoff for performance feedback. Recent articles. Tips for negotiating compensation May Dying after leaving AMA September Tough choices: the right diuretic for heart failure and the best July Raises and subsidies are back on the table May Is the ED admitting too many patients?
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