Part 5: DO NOT RESUSCITATE
We are often asked if someone has to have a DNR (Do Not Resuscitate) in place to be on hospice; the answer is no. However, when a patient is on hospice and given a terminal diagnosis with a prognosis of 6 months or less, death is expected. When the death occurs, when the heart stops, there are very few simple heroics that will revive the hospice patient. If a patient and family have chosen to be resuscitated, then CPR must be started immediately by whoever is present. If the hospice nurse is present at the time of death (heart-stopping), the last thing she/he would want to do is pound on their chest (CPR) to make the heart start again knowing it might be futile. Our nurses bond with our patients, love our patients, and don’t want to hurt them or cause them discomfort. For the frail, elderly, and terminal resuscitation is very uncomfortable and often times doesn’t work while on hospice. For the frail, elderly, and terminally ill, the body is already very weak so getting the heart started again isn’t always effective. The body becomes so frail that doing CPR can easily break ribs and cause more issues with resuscitation attempts.
We try to be blunt and honest as we educate about what a resuscitation can look like on an elderly person. The patient and family need to have a realistic understanding about resuscitations. Watching a resuscitation of a beloved elderly person is very difficult and not something we want to put our families through. But of course, it is a personal choice to be resuscitated or not, we cannot make the decision for a patient or their family. We can only advise and educate. If the patient or family are not ready and do not was a DNR despite the realistic overview, we will honor that decision, and resuscitation will be attempted at the time of death. The most unfortunate part is that heroic life-saving measures rarely end with resuscitation. If the heart were restarted with CPR, paramedics would be called and the patient then transported via ambulance to the hospital for continued life-sustaining measures such as a ventilator. There is such a directive called DNI (Do Not Intubate) however most often, when life-saving has been initiated, it will most likely be continued.
Turning off the pacemaker and disengaging the defibrillator
Much like resuscitation, a pacemaker with a defibrillator does the same action. We recommend on hospice that the patient have the defibrillator turned off or deactivated. The intended purpose of a defib pacemaker is to resuscitate from the inside. When a patient is on hospice, with a terminal diagnosis and a 6-month prognosis, the stopping of a heart is expected. But with a defibrillator, the heart is manually jolted back to life which is often described as feeling like being kicked by a horse on the inside. It is severely painful and incredibly uncomfortable and will prolong that state for an indefinite period of time as the heart can sustain. The defibrillator will attempt to keep the heart beating. For optimal comfort, we recommend not having these items and let the heart naturally stop when the time comes.