Life and Death Decisions: An Emergency Physician on Taking Control During COVID-19 Uncertainty

Know the Facts: DNI and DNR

When a person cannot breathe on his or her own, a breathing tube placed down the throat (a process called intubation). The tube is then attached to a ventilator, which breathes for them.

RELATED: Treating Coronavirus Breathing Problems When are Ventilators Used?

I often hear families or individuals say, "do everything, give it a shot." But it's not that simple.

Ventilators can cause trauma to the lungs and there is no guarantee a person can be successfully taken off of the ventilator. Resuscitation may also involve medications to keep blood pressure up and fight infections. It can include the decision to discontinue medications, fluids, or feeding — or maintain them.

Invasive Procedures

Similarly, CPR is rough and can cause broken ribs, perforated lungs, and internal bleeding. Shocks can be numerous. Finally, if a person is "revived" meaning they have a heartbeat and is getting oxygen, there is no guarantee there won't be permanent damage from the resuscitation or that the person will ever regain consciousness or have normal brain function.

These procedures are invasive. In addition to the breathing tube, a patient may have large IV's in the neck, catheters to capture urine, and monitors that make incessant noise. After weeks of lying in a hospital bed, ulcers can form, putting the patient at risk of further infection.

Questions to Consider on DNI and DNR

Questions to be considered regarding making yourself or your loved one DNR/DNI are the following:

1)  What is the chance of survival? If you are much older, have a lot of health problems, or have a terminal illness with a poor prognosis, will this change the trajectory or outcome of your life? Or will it prolong it with discomfort?

2)  What will you or your family member's quality of life be after resuscitation? Will a person's life be made any better with resuscitation?

3)  What is the level of function before this moment? Was the person happy, alert, interactive, functional to some extent? Or was he or she already dying slowly?

RELATED VIDEO: With palliative cancer care, the sooner the better, says Dr. Elizabeth Kvale, director of the Supportive Care and Survivorship Program at LIVESTRONG Cancer Institutes at UT Health Austin. 

As an emergency physician who now addresses DNR/DNI on a daily basis, the 3 things I want to make clear are:

1)  DNR/DNI does not mean we as medical professionals stop caring for someone. The person is not forgotten. We work together to make the person comfortable.

2)   DNR/DNI does not mean a person or a person's loved one has given up or that this is a guarantee of death. This is merely a directive of what you do/don't wan and what you want to control when you're not able to be in control

3)   This is not a decision you want to make at the last minute or have someone like a hospital committee make for you. It should be well thought out.

If a person wants to place advanced directives, speak with your family and doctor, including the ER doctor, to help with the steps and paperwork.

Better Times Are Ahead

I spoke with my family about what I want. This is a reality, but it doesn't make it our fate. It just makes us prepared, allowing us some control in uncertain times. We prepare for the worst, hope for the best and tell our loved ones we love them, every day. Better times are ahead.

Dr. Cini Thayil is an Attending Emergency Medicine Physician at Mercy Medical Center in Rockville Center, NY.

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