Question Title: HELP - Is it time for a D.N.R. order ? ... Long

Forum: Neurology Forum
Topic: Movement

I just discovered this board, never dreamt such a wonderful thing would exist, and I'm hoping you may be able to provide some direction.

My 69 yr. old father in-law is currently hospitalized and we were just told it's time to consider signing a D.N.R. Following is his history.

Since age 29 he has suffered two stokes, three heartattacks and has had numerous heart/artery related procedures. He is also a diabetic - up until recently controlled by pills only. His problems began in the spring when a toe became infected after a trip to the podiatrist to have his toe nails clipped. Toe became gangrine and had to be amputated.

During pre-op testing the vasular surgeon found a arterial blockage in his neck which was operated on prior to the toe. He then went in to have the toe amputated - at the same time a vasular bypass was performed in his leg to insure circulation to the foot. He released from the hospital - spiked a fever - diagnosed with having MRSA.

After having been back home for a couple of months and finally off IV antibiotics for a few weeks, approximately 3 weeks ago he began complaining of a sore, stiff neck and thought he was also coming down with a cold and had spiked a slight fever - 99-ish (this was a Sat & Sun). By Tues. a.m. he was suffering from shortness of breath. On Wed. he was admitted to the hospital in complete renial failure. That evening he went into cardiac arrest, CPR was performed and he was intebated. He was then moved to CCU. On Friday they tried to ween him from the vent - he had another cardiac episode.

Since this time it has been concluded he is septic, his heart rate is irregular, his kidneys are now functioning, his fever has ranged from 99 to 106, his blood pressure has been all over the map, he now has pneumnia (sp) and is completely paralazed and his reaction is poor at best. He is at a small commuity hospital which is treating his symptoms but not, we believe, searching for the cause.

A neuro-surgeon was brought in and believes he has suffered a spinal vascular incident. He has bulging on one side of the C2 and bilaterially on the C3 and is a quadraplegic as of now. We were told he will never come off of the respirator and we should now consider a D.N.R. However, after numerous scans, MRI's, spinal taps, etc. which have all come up inconclusive we fear a D.N.R. is too pre-mature.

I know it's so difficult for you to respond a great deal without having the patient and his medical records in front of you - but do have any feedback whatsoever on this situation? We realize he has one hell of a medical history and is actually quite fortunate to have lived to this age - but we just need to be sure everything possible that can be done has been done. We are close to North Shore University Hospital and are trying to get him transferred to this hospital.

Any feedback, thoughts, ideas, suggestions .... whatever ... would be greatly appreciated.

Thank you for your time.
Debi

Dear Debi,

The decision to do not resuscitate (DNR) can be a difficult one. The purpose is to give physicians and nurses advanced directives in case further medical issues arise (eg. cardiac arrest requiring CPR, further renal failure requiring hemodialysis etc.). When making the decision, the most important guide is to keep in mind what the paitent may have expressed or wished PRIOR to requiring medical attention. For example, many patients state that "I do not want to be on a respirator....etc". I am not able to comment on prognoisis in this particular case, however, sometimes prognosis can be determined following cardiac arrest in as little as 3 days. The patients clinical exam is very important and can provide clues to long term outcome/prognosis. Once again, work with your doctors and keep in mind what the patient may have wanted. Good Luck.

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