Can you be held liable for resuscitating a patient who has a DNR order?

A New Mexico woman, suffering from Dercum’s disease (adiposis dolorosa) which causes painful fatty tumors, is suing a Santa Fe hospital and an emergency physician claiming she was the victim of two negligent acts in 2016.

One, according to the Albuquerque Journal, she told hospital personnel she was allergic to Dilaudid but went into cardiac arrest after receiving an injection of the drug.

Two, despite the presence of a lawfully executed “do not resuscitate” (DNR) advance directive, she was successfully resuscitated and now faces continued pain and medical bills.

The staff had been aware of her DNR order and had even issued her a purple bracelet labeled “DNR.” However since the cardiac arrest was allegedly caused by an allergic reaction to Dilaudid, the staff may have felt her problem was not related to her illness and would likely result in a successful resuscitation.

While researching this subject, I found several instances of patients or families suing hospitals and doctors for failing to heed a DNR order or what some have called “wrongful life.”

However, I found only one major case that had gone to conclusion. A Georgia woman had both an advance directive and a healthcare proxy—her granddaughter. She was admitted to a hospital for a cough and eventually required a thoracentesis. The healthcare proxy agreed to allow the procedure to be done but specifically said her grandmother did not want intubation or mechanical ventilation.

A 2017 paper in The Journal of Clinical Ethics said the patient was temporarily intubated and ventilated during the thoracentesis. She was extubated, but a bout of respiratory distress was treated with intubation and mechanical ventilation again without consulting the granddaughter. The patient died two weeks later.

The granddaughter sued, and the hospital settled for $1,000,000. I believe this is the first such case settled for that much money. The biggest problem was failure of the doctor to communicate with the healthcare proxy.

Many issues in medicine are not black or white. Here’s the other side of the story. An elderly Boston man suffered a cardiac arrest in a hospital CT scanner and was resuscitated. The resident who treated him wrote that during the code, a nurse discovered a 6-year-old advance directive saying he did not want to be resuscitated in his chart.

But the code team noted he had walked into the hospital for the test and felt certain they could save him. They contacted his son and healthcare proxy who said “My father would want everything done to save his life.” The code was successful. He was weaned from mechanical ventilation and extubated after a few hours. He thanked his doctor and was discharged from the hospital two days later.

Some take-home points:

A DNR order and an advance directive may not necessarily be the same. For more information, read an interview with the plaintiff’s lawyer in the Georgia case.

Whether to resuscitate a patient or not may depend on the circumstances [e.g., whether an event is likely reversible or not], the wording of an advance directive, and/or the wishes of the healthcare proxy.

If possible, explain the possible scenarios and outcomes of resuscitation and DNR to your patients and their families well before a cardiac arrest occurs.

Communicate with patients and their healthcare proxies.

How the public is misinformed about the outcomes of CPR

A survey of 1000 volunteer adults found 71% regularly watched medical television dramas, but only 12% said the shows “were a reliable source of health information.”

The participants were given some brief vignettes describing scenarios where CPR was administered—a 54-year-old who suffered a heart attack at home and received CPR by paramedics, an 80-year-old with a postoperative cardiac arrest in the hospital after surgery, and a post-traumatic arrest in an 8-year-old.

Those surveyed estimated CPR success rates at 57% to 72% and rates of long-term survival with neurologic recovery at 53% to 64%.

What comes after the Heimlich maneuver?

At the end of an otherwise informative article about the nuances of performing a Heimlich maneuver, New York Times science reporter Jane E. Brody recommends that if all else fails, a cricothyrotomy should be attempted.

She goes on to briefly explain how the procedure is done. In the right hands, a cricothyrotomy is safer and easier to perform than a formal tracheostomy. However, for a layperson who has never seen either procedure done, does not know the relevant anatomy, and has never put a knife to anyone's skin, it is highly unlikely to be successful.

Ms. Brody includes a link to website with some static drawings of the procedure. The site is called Aaron's Tracheostomy Page and it bills itself as "The Internet's leading tracheostomy resource since 1996."

Here's an excerpt from that description of the operation:

"3. Take the razor blade or knife and make a half-inch horizontal incision. The cut should be about half an inch deep. There should not be too much blood." Yes, there should not be too much blood, but sometimes there is.

Both the Times article and the reference repeat the medical urban legend that the barrel of a ballpoint pen can be used as a breathing tube.

A 2010 paper found that due to high resistance to airflow, most ballpoint pens are not adequate airways, and the two that were acceptable (the Baron retractable ballpoint and the BIC Soft Feel Jumbo) are unlikely to be on hand. An earlier paper also reported similar high airflow resistance with ballpoint pens.

A small study involving inexperienced junior doctors and medical students found that they were able to successfully perform cricothyrotomies in only 8 of 14 cadavers. Injuries to the thyroid and cricoid cartilages were common.

Remember these important points—cadavers don't need an airway in a hurry and they don't bleed.

Evidence of successful cricothyrotomy by bystanders is lacking. A 2010 review of American soldiers killed in Iraq between 2003 and 2006 noted that five of those who died appeared to have had attempts at cricothyrotomy, all of which failed.

I once was asked to see a patient whose "cricothyrotomy" done in an ED by an experienced emergency physician and a resident turned out to be a laryngotomy. The tube was inserted directly into the larynx.

To the uninitiated, surgery looks easy. Last year I blogged about Malcolm Gladwell's outrageous claim that just about any college graduate could become a cardiac surgeon.

I suppose one might say "What have you got to lose? The patient is dying. Try the cricothyrotomy." I can’t stop you. But be certain it is necessary, and realize your chances of success are extremely low.

If you’re considering it, at least look at some of the many instructional videos available online.

Warning: Graphic. There is some blood. Here’s one by an ED doc. In a non-hospital setting, you would not have all the help and equipment he had. Here’s another, this time by a surgeon—with lots of help and equipment. Both patients were relatively thin.

Now imagine doing it with a pocket knife and a ballpoint pen on an obese person. Still think it’s easy?

CPR in space is possible, maybe

Last summer I wrote about the many problems associated with performing surgery in outer space. [Link here.]  Not surprisingly, I was highly skeptical about such issues as training astronauts to operate on each other and the difficulties in taking along enough supplies to deal with unexpected trauma and surgical diseases.

At least one commentor on that post felt that NASA had all the answers. But another said, “What NASA never wants to discuss publicly is the scenario: If X happens then you die.”

Not to be outdone, the European Space Agency recently released a YouTube video illustrating how cardiopulmonary resuscitation could be carried out in a weightless environment.



You can see that the technique is rather awkward and questionably effective. To my knowledge, the rescuer falling on the victim is not currently recommended in the latest CPR guidelines.

Assuming that by some miracle the victim survives CPR, what would happen to him? Would he be transferred to the intensive care unit on the spaceship? Would there be a ventilator? What about an endotracheal tube and someone to insert it? Who would monitor the patient? Would that person be subject to work hours limits?

Here’s what I think.

If you have a cardiac arrest on the way to Mars, you’re not only in deep space, you’re in deep doodoo.

Is normal saline bad for the kidneys?

Answer: Yes.

This week, the two heavyweight medical journals, JAMA and the New England Journal of Medicine, featured papers describing the effect of certain intravenous fluids on the incidence of renal failure in critically ill ICU patients.

The JAMA paper compared normal saline (relative to human plasma, a high chloride-containing solution) administration to more physiologic, low chloride-containing IV fluids such as Hartmann’s solution (very similar to Ringer’s lactate) or Plasma-Lyte 148. It showed that using the low chloride intravenous infusions led to a statistically significant decrease in the incidence of acute kidney injury and the need for renal replacement therapy.

The NEJM paper compared the use of intravenous hydroxyethyl starch (HES) fluid resuscitation to normal saline and found that patients given HES had significantly more acute kidney injury and needed more renal replacement therapy. Bear in mind that HES is actually a solution of 6% HES in normal saline.

Neither study found a significant difference in mortality rates related to the various solutions used.

Both studies were performed in Australia during different time periods. The JAMA paper was based on research from a single hospital in Melbourne in 2008-2009 and was a before-and-after trial while the NEJM study was multi-institutional, randomized and prospective and took place from December 2009 to January 2012.

Is normal saline bad for the kidneys? Yes. If you compare high chloride normal saline to lower chloride solutions, normal saline causes more renal dysfunction and need for renal replacement therapy. Normal saline vs. HES really compared normal saline alone to 6% starch in normal saline, and showed that the starch is probably the factor causing renal injury.

So what is a clinician to do? Normal saline is not really “normal.” Solutions containing amounts of chloride closer to that of human plasma are the correct ones to use. As we surgeons have maintained all along, Ringer’s lactate should be the resuscitation fluid of choice in the U.S.

See the table below for the amounts of sodium, chloride and buffer in standard IV solutions.

Less is more. Conventional wisdom challenged in two NEJM articles

Classical views on fluid resuscitation and nutrition in critically ill patients were questioned in two papers published today in the New England Journal of Medicine.

A large study involving febrile, under-perfused children in Africa reveals that those aggressively resuscitated with fluid boluses of either saline or albumin had higher mortality rates than a control group who were not given boluses of fluid. The study was stopped earlier than planned when the research group’s data and safety monitoring committee performed an interim analysis. This paper adds to a growing body of research that shows that large-volume fluid resuscitation may be harmful in many situations.

A second article demonstrated that in some 4600 critically ill patients given enteral nutrition, late (day 8 of ICU admission) initiation of parenteral nutrition to supplement the enteral nutrition and achieve caloric goals leads to fewer complications and faster discharge from the ICU than patients whose parenteral nutrition was started within 48 hours of their ICU stay.

The papers are accompanied by editorials (here and here) that provide perspective and as usual caution against overly interpreting the results.

Although the messages seem quite clear (especially regarding large-volume fluid resuscitation), clinicians should read both papers and decide for themselves.