No Chest Compressions

File under: Something New Every Day

The group home patient with a history of mental retardation was found unresponsive in his wheel chair. The small frail man has significant kifofis. His body is flaccid and he cannot even hold his head up. The quick story is he was found that way this morning. Normally he is alert. He seems to be having periods of apnea, but his color is good and he has a decent radial pulse. I’m guessing CVA. “He’s a no compression,” the aide says.

“A DNR?”

“No, he’s no compressions only. He doesn’t have a bracelet.”

“But he’s a DNR?”

“You can breathe for him.”

“But I can’t do compressions?”

“Right.”

“So he’s a DNR?”

“No, he’s a full code, just no compressions. He has osteoporosis and compressions won’t work. They’ll break his ribs. We have a doctor’s order.”

“I’ll need to see that.”

They produce it:

“Notice of “No Chest Compressions” for “Patient name”

In the event “Name” goes into cardiac arrest, immediately call 911 and start rescue breathing. When emergency personal arrive, inform them of no chest compressions and give them a copy of the Dr’s order for no chest compressions along with this notice.

This has been agreed upon by “state agency responsible for patient” and ordered by his PCP.

I shake my head. I don’t argue with the aide, but I am thinking to myself — this isn’t going to fly. Our state is pretty rigid on its DNR/resusitation order forms and this one — while being agreed upon by a doctor and a state agency — is most certainly not valid. Additionally it is over two years old. Our DNR orders must be updated every six months.

I think it is a way around what I am told is a rule that no patient in the care of the state can have a DNR order, so this is not a DNR order, per se, but a half-assed resucitation order. I suppose it would be okay if I took a scapel out and sliced the patient open and reached in an did open cardiac massage just so long as I wasn’t doing compressions.

Fortunately, the patient doesn’t code on me or get much worse than an occasional apniec pause that responds to stimulation. At the ED, I relay the info to the hospital staff who all admit they have never seen such an order. I later talk to a hospital staffer who tells me of a lengthy conversation he has with the case worker. The case worker tells him he can defibrillate the patient repeatedly, but can’t do compressions because they will break the patient’s ribs. He doesn’t seem to understand that you need to do something to circulate the blood. You can intubate and defibrillate, the case worker says again.

***

My preceptee, who wasn’t with me that day, asked what I would have done had the patient coded. I would have called medical control, I said. I would have said, “Doc, this what I got, Whaddya think?”

That’s why they get the big money.

8 Comments

  • armed_and_christian says:

    That’s really weird. I’ve never seen or heard of such an order, either, and I have to wonder at the skill of the doctor who wrote it. I’m with you: call medical control and let them make the big decisions.

  • Nathan says:

    Hell. I would have worked it as a full code. That’s not a valid DNR order, and obviously I don’t need to quote “When in doubt, resuscitate.” but it’s pretty meaningful here. I would have started full code and called med control and if they told me to discontinue then so be it.That’s probably the most asanine order ever though. Even perfect CPR performed ideally on ideal patients breaks ribs.

  • Anonymous says:

    Doesnt CPR usually break ribs?Isnt the rule these days “hard and fast”?

  • Anonymous says:

    I saw a DNR once which had something on it stating only to do a first round of CPR/defibrillation and then discontinue. No drugs, no advanced airway.

  • Anonymous says:

    Actually, as a decision maker for an individual with osteoporosis I am facing this dilemma now. Guidance in our state’s code suggests that I do not consent to a DNR unless there is a compelling reason – such as terminal illness. However, I am aware that manual CPR would be devastating to the body of the individual. I am considering something like what is being mocked above and just posted on Facebook to ask my EMS friends. Any useful suggestions?

    • medicscribe says:

      You can’t do CPR without chest compressions. If you don’t do chest compressions it is not CPR. The patient’s heart has stopped. Aside from opening their chest and doing cardiac massage, there is no way to make the heart pump without doing chest compressions. Chest compressions are by nature traumatic. Ribs are often broken by the act. The alternative of course is do nothing and allow the person to die. For many people, particularly when the death is a natural one, that is a preferred choice. CPR is really designed for healthy people who drop from a sudden cardiac arrhythmia or other person who has a fixable cause to their sudden collapse. It is not meant for 92 year old bedridden cancer patients. A paper that says Do CPR, but not chest compressions is basically the same as a DNR, except it requires responders to provide ventilations to a body that without compressions has no way of circulating the oxygen to the heart.

  • Thinking and Caring says:

    I am dealing with a similar situation related to a a relative in her mid-nineties whose sternum was removed about 17 years ago when the wiring holding her rib cage together following a triple bypass played host to an infection. She was informed that chest compressions could kill her and does not want them to be administered if the situation were to arise; but she otherwise has no desire to be denied other emergency lifesaving care. However, faced with a rapidly growing parathyroid tumor 2 years ago she chose surgery and came out of it well. I am not a medical professional but I am capable of imagining there are other life-threatening conditions besides the heart stopping that would signal the need for different types of measures that a simple DNR might prevent her from receiving. This would be contrary to her wishes. I understand there is such a thing as a Limited Code status and am exploring what the variants on this might be. Suggestions welcome.

    • medicscribe says:

      Many states are adopting polst or molst orders where a physician spells out everything in detail, a menu of options. For instance intubate, give IV fluid, but no CPR. The standard DNR order only applies if the patient has both stopped breathing and their heart has stopped. These orders are if coordinated properly through the state, honored by EMS, which previously would only honor an official DNR.

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