Older Patients, Wiser Care

He Chose "Do Not Resuscitate." So Why Did He Wind Up With Intubation, Something He Didn't Want?

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The case: Would he want a machine to breathe for him, if he got worse?

"Doctor, I'm not feeling so good, but I think I'm gonna make it."

Mr. P lay in his bed one Friday afternoon, breathing hard and wheezing a bit. It was the fifth hospitalization in five months for this dignified 84-year old black veteran. He was the kind of older man who never leaves his house without having a nice hat on. Now he lay in a hospital bed, bare-headed and tired-looking. A visiting home nurse had sent him to the ER after she found him coughing and short of breath. The doctors had found that both his asthma and his congestive heart failure were out of control.

I sat on the edge of the bed and held his hand. He certainly looked sick, but the hospital team had told me that he'd gotten much better, compared to the day before. They were hoping he'd be well enough to go home in another few days.

I eyed the bipap breathing machine in the corner by his bed. When connected to a tight-fitting mask on the face, a bipap machine helps push air in and out of a person's lungs. It can help a person with asthma or chronic obstructive pulmonary disease (COPD) get through a bad period, and it had helped Mr. P earlier in the day.

But what if his breathing got worse? Then he'd need to go to the ICU for intubation: a breathing tube down his throat, and a ventilator fully breathing for him.

I wasn't thinking that things would come to that. After all, Mr. P was improving. But while Mr. P had said several times that he wanted to be DNR-- do-not-resuscitate, which meant that if his heart stopped, we shouldn't do CPR or use the electric paddles to try to jolt his heart back to life (aka "defibrillation") "“ he hadn't been specific about intubation. This mattered because intubation is usually part of emergency efforts (also known as "code blues") to save a person who's unresponsive and probably on the edge of death. But intubations don't only happen as part of a code blue: People with pneumonia or COPD sometimes need to be intubated for a few days because they're too tired to breathe on their own.

If Mr. P's heart was beating but his breathing got dangerously bad, would he want a tube down his throat?

The challenge: It's often hard to discuss preferences regarding life support

It seemed wise to try to clarify this point. I didn't want to sound pessimistic, but sometimes people can unexpectedly take a turn for the worse. I knew Mr. P's wife had recently died after spending months on the ventilator in the ICU. That's the kind of experience that can leave people with strongly held ideas about how far they're willing to go for a chance to stay alive.

"No, I don't want any of those shocks if my heart stops," he said. "But for the breathing"¦I wouldn't want the tube and the breathing machine if I weren't ever going to get better. But it might be okay for a little while."

"Sounds like you're willing to be on the breathing machine for at least a little while, especially if the doctors think you might get better," I said, trying to make sure I'd heard him right.

"Well, I don't know," he sighed. "I guess I'll just have to decide about that in the moment, if things come to that."

I tried to gently point out that usually people are too sick to decide in the moment. But Mr. P was tired and wanted to rest. I told him that we could continue the conversation later, and that I'd keep him in my thoughts. Then I updated the inpatient medical team. "So, no CPR, no shocks, but he's not sure about intubation," the medical resident recapped. "Well, he is getting better."

Unfortunately, that unexpected turn for the worse came the very the next morning. Mr. P had been found unresponsive at 4 am, with no pulse. The nurses had called a code blue. "We didn't shock him, but instead we gave him epinephrine and other drugs to try to get his heart going again," the resident told me over the phone, his voice tired. "And we intubated him to give him the most oxygen we could. But his heart didn't come back."

"The doctor who intubated him said it was very easy, no resistance at all. So I don't think he knew what was happening," the resident continued. "He didn't look uncomfortable."

And so Mr. P died: no shocks, no CPR, but a tube in his throat.

The solution: Understand the defaults when a choice hasn't been made

I thought back to my conversation with him. Both the resident and I had known how unlikely it would be that Mr. P could decide about intubation in the moment, as he had wanted to do. Maybe I should've spent more time clarifying that to him. I could've told him that the default, if no decision has been made, is to intubate in an emergency. I could've informed him that most people are unresponsive in an emergency. I also could've told him that he was unlikely to survive a code blue, whether or not he was willing to have CPR and shocks. Would he then have decided to be do-not-intubate, like most people who are DNR?

Would that have helped him have a better death?

In the end, I'll never know. Knowing Mr. P, I think he would have preferred not to die with a tube in his throat. The trouble is that none of us, whether doctors, caregivers, or patients, has a crystal ball to tell us when a code blue is coming, or when we'll have run out of time to make decisions.

On the other hand, I know for sure that during that last talk we had, Mr. P preferred to not yet decide about intubation. Instead, we sat together, and he cried as he talked about how much he missed his wife. "You can't ever get over something like this," he had told me, "but you do the best you can."

My prescription for caregivers:

  • Expect that at the start of most hospital stays, doctors will ask about preferences regarding CPR, defibrillation (aka "shocks to the heart"), and intubation. Even if preferences have been documented previously, it's good practice to check and make sure they haven't changed.

  • Although sometimes decisions about these life-supporting interventions can be made in the moment, often they can't. Know that during an emergency doctors usually will try whatever life-support hasn't been explicitly declined.

  • Know that these are hard topics to discuss, for patients and caregivers, and for doctors too. But broaching the conversation may bring up an answer, or at least get the person thinking. Do the best you can.