At 16, I graduated high school. At 20 years of age, I graduated with my BSN and successfully landed my first nursing job in a progressive care unit, where I worked for only 6 months before I was promoted to the corresponding ICU. I have worked there the last 8 years and as you can imagine, I've seen a lot of miracles, but also a lot of deaths. Some of the deaths were probably for the best, some were untimely (such as the new babies our unit sees) and some were prolonged for far too long, and really, only promoted more suffering. The prolonged deaths tended to be 80 and 90 year olds who, were unwilling themselves to let go, or who had family members in denial about their condition. Although I am not sure of the "right" age to become a DNR/DNI, I sometimes think to myself there's no way I want to be full code when I become their age. However, I really don't know when I would want to change my status; I am not even 30 years old, so I feel there are many more years for me to accomplish things. At the same time, I know I won't be full code forever. What is your opinion?
Sep 18, '17
Well, I'm 52 but healthy and strong... no meds, normal VS, normal labs... not the specimen that I was at 32 but still got it going on.
I don't think about it so much in terms of age as I do health and vitality. So long as I'm healthy and have the physiological reserves to give a decent chance to buck the odds and have an intact discharge home from the hospital, I'll take my chances... though I have a pretty explicit Living Will which refuses a G tube and a trach and all care 2 weeks post ROSC and my DPOA is armed with a several page document seeking to clearly express my views of life: quality >>> quantity and my view that if I can't specifically and unambiguously request some treatment or sustaining care that it must be presumed that I am refusing it... Likewise, that if I cannot control my limbs sufficiently to lift food or water to my mouth then it must be presumed that I do not want others to do so for me, even if I take it once proffered (because I consider that a mere reflex action). If in doubt, they are free to construct a robot which, if under my sole control, I activate in order to bring food or drink to myself.
Probably by the time I'm 70, I will say "If it's a witnessed arrest, with immediate provision of CPR, I will permit 3 shocks and one dose of epi but no intubation at any point"... if that doesn't get me back, I'm happy to transition.
If I make it to 80, don't even bother.
Sep 18, '17
I cannot keep the terms straight, and new and improved versions come out. But every single adult over the age of 21, or even 18, should have an advanced health care directive (and there are probably different names ?) about what they want done.
Terri Schiavo is unfortunately the perfect example, she was 26 years old. It is not picking an age that matters, it is what you want done in the event of any terminal illness or injury. There are vibrant active healthy 90 year olds and one foot in the grave 60 year olds.
Everyone thinks they will live forever and die peacefully in their sleep.
If I have to pick an age it will always be 5 years older than whatever I am.
(I did work ICU 10 years and do understand exactly what you mean.)
Sep 18, '17
Interesting question… but – like the chicken and the egg – there is no real answer.
I believe this to be more of a “What condition am I in?” than a “How old am I?” question.
I’ve met people in their 90’s who I would guess for 60 and people in their 60’s who I would estimate at 90. The point remains: is there quality life left to be had? For instance, if I’m 30 years old and going to come out vigorous resuscitation only to be my husband’s ‘turn and wipe’ wife, no thanks. But if I’m 80 and was just out golfing with him yesterday… and could possibly be doing it again with a little rehab, then bring on the broken ribs!
I would definitely say that DNR / DNI is more of a “case by case” than a “How old am I” situation.
Last edit by ladedah1 on Sep 18, '17
Sep 18, '17
I don't think this can be answered with something as simple as an age. I also don't think that it's a 'one size fits all' approach for those with irreversible conditions. While I would not want a permanent trach, a Gtube that would never be reversed, a machine breathing for me, and needing someone to turn me, clean me, bath me, and change the bandages on my bed sores that I cannot even feel because I am paralyzed from the neck down someone else may want all these things done for the slim possibility of becoming better (whatever better may be) someday or may take this route over death. It is not my call to decide for someone else when to take the right for medical care away. This has to be a personal choice.
I think that death is something that people in our country need to talk more about and not shy away from the conversation as if by not discussing it we will prevent it from happening. The fact is, all living things die and each and every one of us will be there someday. We may not have an advanced warning that our time is near, such as a terminal diagnosis where we know we must make choices for end of life care with what we want done or not done.
It could be sudden and that's when things get sticky. By having an advanced directive that clearly spells out our personal wishes takes this burden away from our loved ones and allows them to know what we would want in a given situation so that they will (hopefully) honor our last wishes.
My grandmother lived with her daughter at one time in her life but named my father as her health care surrogate. Her rationale was that he would honor her DNR and let her go when it was her time. Her daughter, as she had said, would turn her into a vegetable. Her husband had been bed bound for several years after having multiple strokes. She cared for him until the day he died with no help from anyone else. She did not want to have her last days or years like his were and did not want to be brought back for that kind of life. The irony of her story was that when she did code at an ALF, they misplaced her papers so the EMS did code her and my father found her in the ER with an external pacer and a ventilator. The LAST thing that she would have ever wanted...and she was 95...and she could not care for herself like she wanted to and was wanting to die before this happened. He had to remove life support. She survived. Luckily, for her, it was only for a couple more days. She got to say goodbye to all of her children that were still alive and went peacefully. A few hours before she slipped back out of consciousness she was lucid, like so many patients are in those final hours or days. After going through a code I thought for sure she would have rib pain, or at least her normal debilitating hip pain that she always had. I asked her if she wanted anything for pain and she was able to clearly state, "No, honey. I don't have any pain". This was something that gave us all a lot of peace to know that since she had been brought back against her wishes (because when being extubated and taken of the pacer a few hours earlier, it sure did look very painful).
Sep 18, '17
I do not think it is about age. It should be about the proverbial "whole patient" and the complexity of measures needed to keep him or her alive, plus wishes/beliefs of THE PATIENT, if they are known and documented. Family, even "next of kin", should have way more limited rights to dictate their wants and wishings than they have now.
I had to take care for some otherwise strong as bulls 20+ year olds who were officially proclaimed "cortically" brain dead but were not given death certificates according to "family wish". Thus recognized ans being not quite dead while not exactly alive, those poor beings led completely vegetative existence - with signed "full code" orders. I run several codes on them - they were usually quick and simple to resustitate because they were in good health not counting global lack of cortical brain function. All the time, I couldn't get a question out of my head: what was the purpose of doing what we were had to do with them? The care was quite complex (as you constantly chasing one complication after another), very expensive and absolutely meaningless. I felt it as depressing.
For some conditions, we have strict numerical values. Patients with MMSE <9 (severe dementia) done by two independent providers over a period of time and with confirmed exclusion of reversible causes, probably should be made DNR. What we should, probably, tell people more is that "doing everything to save his/her life" has success level in terms of "getting heart beating and lungs breathing" of less than 5% for patients with 3 or more failures of complex organ systems. This makes it less than 1 chance out of 20 for someone with CHF III and below, ESRF and COPD on oxygen. Plus, being "coded" is excruciatingly, unimaginably painful way to die.
Sep 18, '17
Honestly... I think once I hit 70 I'll make myself and my husband DNR. Probably earlier if we age horribly and have 1 or more chronic health issues... I honestly I can't say that I am interested in living past the age of 80 unless my life is super miraculous.
Sep 18, '17
I'm not sure for myself yet (and I definitely think it depends on my overall health at the time & the outlook). But I did take care of a patient who had an advance directive making them a DNR if over age 80 or diagnosed with a terminal illness. (The pt was over 80, but had signed it years before.)
Sep 19, '17
I got my doctor to sign DNR orders for me after participating in several futile codes. I hated the feeling when I broke ribs during compressions and I didn't want it to be done to me. Now, I'm willing to have antibiotics and (very) short-term ventilator support IF I'm alive and there is a chance I may be able to return to normal functioning (or whatever serves as normal functioning considering my health history). But if I'm clinically dead, PLEASE leave me that way. And for God's sake, don't ever let me be in a state where I have to be turned, cleaned up every two hours, fed, and bathed by someone other than myself. I once was asked when I thought would be a good time to die; I said "five seconds before my feet cross the nursing home threshold". I meant it. I still mean it.
Sep 19, '17
As someone that works with brain damaged children (many have gtubes,trachs,and vents for a decade) I don't think this has anything to do with age.
Sep 19, '17
I am an organ donor so I don't believe that I can be a DNR/DNI as they would need to intubate me to keep perfusion long enough to procure any viable organs, but that is the only circumstance that would be acceptable. Even at my age (38) I don't want to be given extreme CPR or be stuck attached to tubes and wires for however long my shell of a body would last and needing people to clean me constantly as I void all over the bed. Death is a much better alternative.
Sep 19, '17
My personal belief is that everyone should be required to turn in a completed advance directive to graduate high school. We all need to consider what we want out of life, and that means knowing how we want to respond to the possibility of it ending. I finally did my AD at the age of 28, I've chosen my decision makers, and I am so happy knowing that I will never endure any treatments I wouldn't want. My mom also filled out hers AND got changed to DNR-A2, so she is all set!
(PSA: choose your decision makers wisely! Know their beliefs, and keep them updated on your wishes! It always kills me to have patients who never considered the details surrounding end of life, resuscitation options, etc., and their families struggling to do the right thing. I respect it if a frail 93-year-old wants the works, but it should be THEIR decision, not a great-niece who has never discussed anything of that magnitude with the patient before.)
Same as pretty much everyone above, it more matters what my overall health is than my actual age. By 70-75 I'm pretty sure I'd be comfortable with officially changing my code status, but I would certainly consider it earlier if needed. I think if I were to develop a chronic illness that took an exorbitant amount of time and effort to control or left me in great pain, that would be the point at which I'd want them to let me go. If I can't read, play the piano, move around at least a little, and enjoy my food, that is not quality of life for me. And no one had better let me get to the point where I need company in the bathroom or I will haunt them all.
Sep 19, '17
Agree with PPs that quality of life is much more important than age, although I'm surprised that so many are choosing 70 as a cutoff. IIRC that's not even considered "extreme old" or whatever anymore. Three of my grandparents lived/have lived into their mid 90s and up until recently were doing well, living independently, etc.
OT: OP, you have an ICU with babies and 90 year olds? What kind of place is that?
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