One of the most difficult and personal decisions you will ever have to make is whether or not you want heroic measures to prolong your life in the final stages. Heroic measures include such interventions as mechanical ventilation (breathing machine) or cardio-pulmonary resuscitation (CPR).
These extraordinary measures to extend life (or prolong death, depending on how you look at it) have become so common in our technologically advanced world, they are actually a standard of end-of-life care.
In most cases, these measures will always be taken unless you indicate otherwise in a Do Not Resuscitate Order (DNR). People who have been diagnosed with a life-threatening illness such as cancer, or even relatively healthy people being admitted to a hospital, may be asked to consider a DNR.
What Is Cardio-Pulmonary Resuscitation (CPR)?
For most people CPR is something they have only seen on TV or in the movies. Unfortunately, it is difficult to tell what is really going on with the patient in a show. Furthermore, CPR on TV is almost always successful in saving a patient’s life. Without a clear picture of what CPR is, and isn’t, it is hard to make a decision about whether you want it.
First of all, it is very important to note that when a person receives CPR they are, for all intents and purposes, not alive. They do not have an effective pulse and they do not breathe on their own. They do not feel procedures being done to them (as far as we know), and without CPR they would probably remain dead.
The intent of CPR is to continue to provide oxygen to the tissues of the body by doing compressions on the chest that simulate a heartbeat. When resuscitation is done in a hospital, doctors make the delivery of oxygen easier by placing a breathing tube (called intubation). They combine chest compressions with the administration of medications designed to stimulate the heart into pumping on its own.
CPR, even when done in the hospital, is very often not successful. When it is successful, there is the possibility that complications may arise as a result. For example, if your brain and tissues did not receive adequate oxygen during the time when you were unable to breathe on your own, damage to those tissues may occur, leaving you with some impairment. Additionally, broken ribs, infection and blood clots are common in patients who have been resuscitated.
On the other hand, even with broken ribs and blood clots, you would still be alive. Even if it isn't successful very often, isn’t it worth trying? That is what you need to decide.
What Exactly Does a DNR Mean?
A DNR, also sometimes called a "code status," can mean many things, depending on the criteria that you outline. Many hospitals now present you with a list of procedures and allow you to indicate which ones you would be willing to accept in case your condition deteriorates.
For example, you may feel that it’s acceptable to receive heart-stimulating medications in an emergency, but the idea of having chest compressions or intubation is not. That can be indicated in a DNR. Maybe you just want to be made comfortable and do not want any form of resuscitation. If that’s the case you can indicate that.
Some aspects of medical care are unfamiliar to most people. How can you make a decision about something if you don’t know what it is or what the ramifications of that choice might be? If there is anything that is not clear to you, be sure to ask your doctor to clarify and ensure that you feel comfortable with the information that is being provided.
Keep in mind that you can only have some input into this decision if you think about it and talk with your loved ones in advance. You may choose to make your wishes known as part of an advance directive that indicates your goals of care when you are not able to communicate. At minimum, document your thoughts and beliefs about resuscitation and keep them somewhere safe and accessible for your loved ones to refer to in the future.
Will I Still Receive Medical Care if I Sign a DNR?
Yes! Sometimes, people feel that if they refuse resuscitation efforts for themselves or their family member that they are "giving up" and that they are going to be abandoned in their time of need. Even with a DNR, unless you indicate otherwise, you can continue to receive treatment up the point of needing resuscitation. As an example, you may still receive blood transfusions or antibiotics if it is felt they would improve your outcome or comfort.
If the focus of your care becomes palliative or hospice, you will still not be abandoned. The treatment you receive may still be aggressive, but its goal will shift to that of making you comfortable as opposed to preventing your death.
How Do I Decide if I Want a DNR?
This is a very individual choice, and one that might change as you continue on your life and cancer journey. In order to make the best decision, there are a few things that you need to consider:
- What is the prognosis of your disease?
- How long have you been ill?
- What other medical conditions do you have, if any?
- What are your beliefs about life-prolonging measures? What are the beliefs of your family, culture or religious group?
- What is your quality of life like?
- What are the goals of your care?
Talking About Your DNR Choice
As with many choices we make, the choice to sign a DNR may be met with a good deal of support from your loved ones, or it may be met with a good deal of distress. In many cases, even loved ones who differ in their opinions from you can and should still respect your opinion.
If there is disagreement about your DNR choice, you may be tempted to change your mind to keep others happy or move on and hope they come to terms with what you have decided. Whatever the case may be, recognize that this is your decision about your life - nobody else can make it for you.
Open communication and dialogue about the decision-making process will often help to smooth over any difficulties within families. Most times, when loved ones understand why you feel the way you do and respect the thought you have put into the decision, they will come to support you.
When they do have a problem with a DNR order, it's usually because they love you, and the thought of you not being around is upsetting to them. If they hear what the choice means to you, they might be willing to put their needs and desires aside.
Summing It Up
Many of us have an opinion about DNR and think we know what we would do if we were faced with a life-threatening or terminal illness. However, it is not possible for us to know how we would feel unless faced with that situation.
Ensure that you understand your options and all of the terms and conditions before you agree to or refuse anything. Talk with your doctor and see if he or she can give you any more information that might make your decision easier to make.
The choice to have a DNR can be very emotional and difficult. It may change and evolve over time. It may be unpopular with your loved ones. But it is your choice.
Eyre, H.,Lange, D., Morris, L. (2002) Informed Decisions. American Cancer Society: Atlanta, GA.
Godkin, M. (2008) Living Will Living Well. University of Alberta Press: Edmonton, AB.
Prager, L., Millham, F. “Living Wills and Health Care Proxies” in Stern, T., Sekeres, M. (eds.) (2004) Facing Cancer. McGraw-Hill Companies: New York. (pp. 335- 342).
Schaffer, M., Norlander, L. (2009). Being Present: A Nurses’ Resource for End- of- Life Communication. Sigma Theta Tau International:Indianapolis.