Why you should consider a DNR order and how to make it stick

Kate Raphael’s New York Times article, What is a DNR Order and Should You Get One?, offers an excellent education for all of us. DNR stands for Do Not Resuscitate. This order needs to be initiated by the patient or the patient’s health proxy; it is essential knowledge for consumers. This patient order instructs workers in and outside a hospital not to restart your heart if it stops. So, the order prohibits CPR and associated resuscitation measures like electric shock to the heart, intubation, ventilation, and certain medications.

This prohibition is an unnatural act for health professionals and frankly for patients/families as

well. So why might someone want a DNR? This quote from the offers a wise response.

In many cases, if you are sick or frail, the harms of CPR “significantly outweigh the benefits,” said Mathew Pauley, a bioethicist at the Kaiser Permanente hospital system in California. Even if CPR revives you, which research shows is unlikely, chest compressions and shocks can cause debilitating injuries like broken bones, punctured lungs, and burns. Some who survive CPR have lasting cognitive impairments because of oxygen deprivation.

As the article states, "People with DNRs tend to be older adults with severe health conditions. In a 2011 study in Canada, some DNR patients wanted to avoid resuscitation because their quality of life was already low or because they feared resuscitation would lower it even more. Others wanted to minimize the emotional and financial burden on their families and the costs to society. Some DNR patients said they wanted to die naturally when their time came.”

Because DNR orders seem drastic, particularly to health professionals, they are often not followed for various reasons/excuses. So, making your DNR order a reality requires persistent communication. One way to communicate your preferences is to have your patient-directed order converted into a physician order. This conversion is called “physician orders for life-sustaining treatment” (POLST). Getting a physician to make this order is a

powerful form of communication and carries more weight with other health professionals. The POLST order is also more precise for health professionals to follow.

A few key points: CPR seldom works for frail elderly patients but is often used. The DNR and POLST orders can be changed at any time. These orders frequently avoid unnecessary suffering for patients and families.

More detailed information on this topic is covered in my book, The Journey’s End, and is available on my website.

Why end of life care needs to change

Casey Mean’s best selling book Good Energy offers a powerful personal analysis of how healthcare needs to change. The book offers individuals lifestyle changes that can significantly improve one’s health. The book also gives advice on why individuals need to trust themselves and not the health system with the management of their chronic illness.

The health system is designed to treat acute care issues. However, that design inhibits healthcare from managing a very different health issue - chronic illness. Chronic illnesses manifest themselves in multiples - if you have one chronic illness you likely have several others. Health care is siloed - specialties seldom coordinate care. This is a real problem. Illnesses like diabetes, COPD, and heart failure are often interconnected. The health system is not interconnected.

Dr. Mean’s illustrates this problem with her mother’s end of life care. Her mother has cancer, but she also has multiple other chronic issues that will cause the cancer treatment to fail. The siloed physicians are oblivious to this reality. This quote from the book describes the problem well: ”The most important thirteen days of my life came from ignoring a team of doctors. Right after my mom’s pancreatic cancer diagnosis, a medical team out of Stanford and Palo Alto Medical Foundation jumped to action, recommending a laundry list of surgeries and procedures…"

Her mother was clear that she did not want extraordinary measures - especially anything causing pain, nausea, and isolation.

“I confirmed with the oncologist: ‘You are recommending an invasive diagnostic procedure that would under no scenario extend her life more than a couple of months and risk my mom dying alone in a hospital room?"

Note this was during the COVID outbreak.

"Even though we were certain that this is Stage 4 pancreatic cancer…and that she has liver failure and almost no red blood cells left?’”

"'Yes, that is what we are recommending,' the doctor replied.”

This physician panel of nationally renowned experts is solely focused on treating the patient's cancer - not on the patient's/family's stated preferences to allow the patient to die without further futile treatment.

The family took their mother home without any further treatment.

“The final thirteen days I shared with my mom were the most meaningful of my life.

If we had taken the advice of the medical system, they wouldn’t they wouldn’t have happened.”

Most patients don’t have a skilled advocate like Dr. Means protecting their care. By the way, that is the role of palliative care but this specialty is seldom part of the acute care treatment model. 

Fundamental changes are needed for end of life care. Pragmatic solutions to these issues are offered in my book The Journey's End.

Helpful visits or way to milk the system?

The Wall Street Journal’s investigative report on Medicare Advantage (MA) deftly uncovers little known concerns about how these plans harm taxpayers. Specifically, these plans exploit Medicare by manipulating coding to increase their payments. This particular report on The One Hour Nurse Visit illustrates how these private insurers use coding to gerrymander a patient's list of illnesses, making them look sicker, so the insurers can collect billions in higher government payments.

This nurse visit strategy is merely one of hundreds of practices by the insurers to increase their government reimbursement through coding. What makes this manipulation of coding possible is complexity. Coding is unbelievably complex and this complexity creates a gray space where MA plans can justify their actions as defensible. In this case, insurers argue

these nurse visits are good for patients, when in fact, the nurses are not there to treat anyone, they are there to gather new diagnoses to increase payments.

Unfortunately, Medicare, which does acknowledge this problem, seeks to cure it by making coding even more complex and by increasing their efforts at fraud oversight. This strategy has not worked and will not work. The answer is to decrease the use of coding for the determination of payments.

Basing premium payments on a patient's list of diagnoses, in theory, is a good idea. However, the continuous increase in coding complexity creates the gray space and invites fraudulent actions like the One Hour Nurse Visit. There are less complex methods of adjusting patient risk for insurance premiums that are technically less accurate but are simple and not subject to billions of dollars in manipulation. Healthcare needs to start embracing simple solutions to our challenges in healthcare payment.