When would you feel it’s the right time to enter a Do Not Resuscitate order for an elderly dementia patient?

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When would you feel it’s the right time to enter a Do Not Resuscitate order for an elderly dementia patient?

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I know of several sad stories where the efforts to save their lives ended in broken ribs or other injuries.

Alzheimer's & Dementia Care Decisions Health Care Directives

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It is up to the person him/herself to carry out an advance directive for themselves that is detailed in what wishes they have for their future. If they have not done this but DO have a POA or guardian, then that person can respond to any hospital admissions that the person doesn't wish resuscitation. This should all be discussed NOW with the person's doctor.

Generally when ambulances are called to a scene they legally MUST attempt reviving a person unless a POLST is hanging in their home (this is an MD paper done with patient/patient representative in the office, enumerating exactly what resuscitation measures may be done and may not be done).

My own personal decision now for my life is to not be resuscitated. What is YOURS and what measures have you taken to insure it is seen and acted on?

You are correct that in the elderly resuscitation is almost never successful, and as a retired RN I can assure you that your assessment that the ribs are often cracked is correct. I have heard them under my hands. Be comforted that the dead don't FEEL this discomfort, and few survive to worry about it later.

Decisions of this sort are plan-ahead. and in the hands of the person involved, or their agent (POA, guardian, next of kin.) and their doctor.

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Reply to AlvaDeer

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Never hurts to try.

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Alva, my directives are in place. As I am reasonably healthy, I choose resuscitation at this point. My mother, when she reached age 90, decided on DNR. That was before she developed signs of dementia (and she lived to age 95 before she died of complications of dementia).

For me personally, if I were to develop a serious debilitating issue that I'm better off escaping before it becomes its worse (like ALS, Parkinson's or dementia in early stages when I could still sign such an order), I'd sign a DNR. I was just curious when others might think they'd do it.

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Reply to Fawnby

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You make all this clear in your Advance Directive now. Kaiser has a beautiful one designating what a quality life means to you, and when you would wish to not be resuscitated. So that you would designate that if you were ever diagnosed with any illness in which you had no ability to direct your care and were unable to make competent decisions for your own life you would not wish to live, nor to have heroic measures to prolong a lift of quanity of days without your version of quality. I did my own DNR at age 70. I already knew I had a good quality of life and wouldn't want to be BROUGHT BACK FROM THE DEAD under any circumstances were I to die. I was an RN. I have very little taste for old age and all its losses. I am more than ready to exit and have zero fear of death. But lots of fears of living on.
Most people do not want to live when their minds are no longer their own.
It's important to say THAT in your advance directive when your mind IS your own.
Most don't understand that you can write up any length of document to attach to your advance directive.
It isn't a money maker any more to keep you alive in hospital. With a good advance directive SCANNED INTO YOUR CHARTS you are protected from all of the what ifs. It it is just some simple pulled off the internet--not so much.

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You put your question under the Alzheimer's/dementia category. If the person has dementia, the time is now for a DNR imo. I prayed daily for my mother to die so she'd be out of her misery with dementia, and she lived to 95+. I thought that was a cruel punishment, personally. Her signed DNR was useless, however, because advanced dementia and CHF killed her.

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Reply to lealonnie1

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My mom is 95.5 years old. Just moved her to memory care. She has a DNR but it's useless; she has asked so many times why can't someone help her die. It breaks my heart. I pray to God every night that he take her in his loving arms and give her the peace she's asking for. 😢

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This doesn’t exactly answer your question—in my previous job, I was required to take advanced life saving every three years. The last two times we did it, a paramedic from the city did the training, a city of about 350,000. One of my coworkers asked him in his years of experience how many times he’d seen CPR actually work. He said “honestly, never” He explained it, done correctly, was brutal, especially on the elderly, and really didn’t work. He cautioned us not to believe what we all see on tv, the miracle recoveries portrayed are the few, rare exceptions.
My dad always made it clear with each hospitalization, even though the documents were in place “don’t go pounding on my chest!” He rightfully feared it, far more than death. With a dementia patient, seems to me a DNR is a kindness

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Reply to Daughterof1930

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In 2013, I saved some guy who had collapsed on the street next to our patio where we were sitting. I remember running to him and going into rote mode with the training I’d most recently gotten in 2006. The model I used was 30 compressions to two rescue breaths. The guy came to when I had my finger in his mouth to clear his airway. He bit down, the paramedics came, and I had to go to the er too for a human bite wound.

It was still worth it.

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Personally, I agree with Lealonnie. I was lucky that both my parents did living wills in their mid-70s (I urged them to do it) with me as their DPOA and health care proxy. They both included strong DNR, no artificial nutrition, no intubation, etc. And when my dad was diagnosed with dementia a couple of years later, we knew it was all the more important to maintain his wishes. He said at one point a few months before his death, around the time he went into hospice “I lived a good life and am not afraid to die.” That comforts me a lot when I think back to decisions I made including nothing but oxygen and comfort meds when he developed aspiration pneumonia and died shortly thereafter. It’s what he wanted. And what I would want for myself if I were elderly with dementia.

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Reply to Suzy23

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Suzy, I was so cross when, after her GP had already stated that Mum should be on palliative care, that a locum GP called for an ambulance for Mum's chest infection. Thankfully, the hospital palliative care doctor was called to see Mum and he made sure she was given comfort drugs only. They ordered a hospital bed for her own home and the district nurse visits were arranged for when they discharged her.

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Actually, NOW is the right time. But it's not just the DNR that you have to consider. It's also what happens when a person with Alzheimers/ dementia can no longer safely eat or drink? The doctor will question the POA or caregiver about a feeding tube. My MIL lived an additional 2 or 3 years bedbound, non verbal & unresponsive due to receiving a feeding tube. Until cancer took her life.

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Reply to JanPeck123

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O.M.G. Speaking for myself, I cannot imagine much of anything worse than that at EOL. I have specifically included no ventilators, no feeding tubes, no tubes of any kind unless essential for comfort care in my advance directive. I also plan to look up the document AlvaDeer mentions that's published by Kaiser (they're our healthcare provider so I hope it's available on their portal).

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As someone who has trained in and performed cpr, we were never told to bear down with such force that you’d break ribs.

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Reply to PeggySue2020

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They shatter anyway when people get really old. Heck, a family friend’s ribs shattered when she was 65.

The women who lived off coffee, cigarettes and amphetamines back in the day have severe osteoporosis now. (Generally speaking)

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Only if you know they'd want it. Some would, while others wouldn't. My sisters are my primary and secondary POA's for healthcare. They've been told I'll haunt them in the afterlife if they *ever* authorize it. My advanced directive clearly states "always do everything regardless of age and/or disability". I don't care if my ribs are broken; they'll heal. Family (or other POA's) shouldn't assume their relative would want everything done except for clear evidence that this is not true.

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Reply to swmckeown76

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No, if you are elderly, not only will your ribs not heal, they will shatter and puncture your liver and lungs and have you die a very very slow painful and miserable death instead.

It’s obviously your life to live as you want, but I wanted to correct your “fantasy” that a couple of broken ribs in a senior isn’t a big deal. It’s a big, giant freaking big deal.

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I know my moms wishes and she would not want to live in the state she is in, so if something were to happen, her directives say not to resuscitate.

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Reply to Jamesj

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I made the decision after placing my mom in Hospice Care to sign a DNR. It is a very difficult decision to make. CPR is violent.

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Reply to Onlychild2024

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My mom passed away a few months ago from cardiac arrest. The doctor resuscitated her once one. I wasn’t there and called me and asked me did I wanna have her resuscitated if it happened again I said no. She was 96 soon to be 97. She was growing weaker from various Falls and losing tons of weight and I was trying to help her in and out of hospitals rehab centers in the last year and a half nothing seem to be bettering her she just seem to be getting worse than her weakness, full transparency, I felt terrible telling the doctor that afternoon not to resuscitate her but in her condition and frailness I felt like it would harm her more than do her any good. I don’t think she would’ve come out of that situation better. She never wanted to live in a nursing facility and I just felt that is the direction she was headed in pretty rapidly. I miss her every single day and cry several times a day and always wonder if I made the right decision. The doctor actually said that I did so I found Solace in that because he said they probably would have broken ribs and it would just made everything that much worse, I don’t know if my mom would’ve wanted that as she didn’t have a living will but I don’t think she wanted to live in suffering. She saw my dad and grandmother on ventilators and said she didn’t want that but she never was clear on her wishes when I asked her directly. So that’s where you have to ask yourself what is the best option for your loved one and would they want to live suffering.
I hope that helps

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Reply to Carriebx

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So sorry for your loss. You should consider attending a grief support group. There will be others who will understand. GriefShare is just one example. They're usually sponsored by churches or other houses of worship, but you don't have to be a member of the sponsoring congregation, nor even religious. They might mention God or Jesus, but the topics aren't inherently religious. One my friends facilitates one of these groups. They might pray or ask people if there are things people would like to have prayer for, but no one is pressured to pray, Do a search online for GriefShare and enter your zip code. You'll receive a list of meetings near you, with the name, phone, and/or e-mail of a contact person. Take care.

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I agree, it is only a decision you can make. It was very difficult, but I signed DNR's on both of my parents when I placed them in memory care. My ex-husband had a stroke, and both him and honestly me regretted the life saving measures they made - he was never the same...some people are OK with that - they just want their loved ones...and you can coulda, woulda, shoulda all day long. For us, it was supremely difficult and for him - it was a horrible life. My parents are currently still "stable" and in mid-dementia stages, however, if something happens where they need a DNR...I feel it's time. <3 I wish you peace on your decision.

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Reply to sbuxmom72

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You need a DNR sorted before it's needed, so you should help your parents arrange that now, while they still have capacity to make some decisions. (I hope that they do.)

If that's not the case, speak with their doctor and find out what you can do in this regard. If you have POA, you should be able to arrange this.
But it needs to be done before it's needed.

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My mother had congestive heart failure around age 88. She also suffered osteoporosis. Her doctor advised DNR when she was almost age 91, so a post was taped to our refrigerator for paramedics for not resuscitate.

For myself, I chose to not prolong life on my Health Directive at age 68 last year. I have osteoporosis and do not want to suffer.

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Reply to Patathome01

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My Mom is 98 and has made that decision herself. She keeps reminding me that she wants to die. She says nobody should live to be as old as she is.

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Reply to jbramwell

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At 95.5 my mom says that too. We have the DNR, but I fear dementia or complications from that will be her demise.

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If you know of your loved one's wishes, those take priority over what you feel.

Elderly dementia patients, if resuscitated for any reason, invariably end up in the ICU, unconscious, with broken ribs. I have witnessed at least two cases in my own family.

I had opted for DNR for my wife who suffered from FTD for 18 years, based on her own wishes. We cared for her at home to the end. I wanted her to pass on in her own bed in her own home.

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Reply to Samad1

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I signed DNRs for both parents as DPOA.
My mother had a massive combo (both hemorrhagic and ischemic) stroke at age 89. From the Neuro ICU, she was transferred to a hospice house and died within 10 days as there was nothing more that could be done for her.
My father lived another 17 months in ALF. When he turned 96, I went to the head of nursing and signed a DNR. He had COPD, emphysema, and CHF. His lungs were shot and I witnessed him at an earlier hospitalization when the nurse asked him if he wanted to be resuscitated, he said "Hell no, I've lived long enough." When he started declining rapidly, hospice was brought in to keep him comfortable until he passed.
Thank goodness for morphine and hospice. I didn't want them to suffer. I have zero guilt for signing the DNRs. It was what they would have wanted.
I was sad that my mom didn't get to outlive my dad and have some peace away from his abuse. (64 years of marriage.) No tears for my father, though, only great relief that his reign of sociopathic narcissism was finally over. My long term PTSD has also improved since then. :-)

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Reply to NavyVet90

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Sending you hugs.

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@Daughterof1930 said "One of my coworkers asked him in his years of experience how many times he’d seen CPR actually work. He said “honestly, never”

Unless he was specifically referring to the elderly, I would be concerned. If it "never worked" then why is the public encouraged to be trained to use it and a priority for the Red Cross.

@PeggySue2020 responded "I saved some guy who had collapsed"

While this shows it can work, the question for this group should be how often does it work for the elderly, frail, or disabled? Also, I would be concerned how much damage might be done no matter how light the compressions. In an emergency, most people forget how much strength they are using.

As a routine question in the ER, I was asked if I wanted my husband to have CPR if needed. My initial reaction was "why not" so I said definitely. I discussed it with our cardiologist and his response was much like many here. Because my husband is not in the best of health and already dealing with so many health issues, would I want to risk the broken ribs to save his life only to add another major lingering issue to recover from along with whatever caused him to need CPR. So we put a DNR in place at our next visit to our geriatrician.

You need to be careful though the DNR is not misinterpreted. I have found even some health professionals think it means you want nothing done... including O2 and tests. A DNR should only come into play if/when the heart stops beating and/or lungs stop breathing. Until then, advocate for whatever you consider the best care to be given.

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Reply to KPWCSC

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The guy I saved was middle age, 45 to 55. I thought he was black while I was saving him but that was due to him actuwlly turning blue which was kind of a blue black.

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It really depends on what the quality of life they are having. If the body is functioning properly, give it a chance. The mind is a different story, if it's really far gone, you might want to go on the DNR just due to the fact that the lack of oxygen to the brain would leave someone in a vegetable state or coma. That would be the biggest fear factor to me! I don't want to be in a vegetable state when I go. Just like if someone at that age were to have surgery, coming out from under anesthesia might not happen, comatose. Usually, most people who go into hospice are required to sign a DNR because it pertains to end of life care,to be made comfortable. It's of course, your decision.

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Reply to JuliaH

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Fawnby: It may align with hospice.

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Reply to Llamalover47

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CPR is violent. Ribs and sternum do get fractured. Occasionally, lungs get punctured by a broken rib - necessitates a chest tube if person survives. If the person has interruption of oxygenation for 5 minutes or more, there will be brain damage. Personally, I am telling everybody I will get my one and only tattoo when I turn 85 years old -
"Do NOT Resuscitate; Let me go to Jesus."

If a person has chronic debilitating health conditions and does not wish for "heroic measures", a DNR is a good idea. As an RN, I have been in many codes and also at bedsides of those who wished to pass without a code. I can't say which is better. It really depends on the person and their loved ones. If everybody is at peace with a natural passing, then a DNR can lead to a lovely passage from life.

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Reply to Taarna

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II have had a DNR not only in my trust, but on file at every hospital near me since I was 65. I use the POLST form that is signed by my doctor and outlines what I do and do not want in detail.

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Reply to MaryKathleen

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In most states, aren't POLST (or MOLST in some states) limited to people with a serious, lifelong illness? They aren't just for limiting health care either. They can be used to specify that the person wants everything done. I don't have one because I'm healthy, but if I ever do, it will say "always do everything". I will never be treated as a throwaway or unworthy of health care because of age and/or disability. If that happens, my POA's know to contact my attorney and sue the hospital or long-term care center who decided that I was no longer worthy of life. I don't care about so-called "quality of life", even if in a coma or with an advanced form of dementia. Every second of life is precious. If you feel differently, fine, but not all of us do. Break my ribs w/CPR; even if they don't heal, at least you didn't treat me as a useless piece of garbage who deserves to die.

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Fawnby, my mum arranged her DNR with her doctor in her mid to late 60s, after her stroke and before her dementia diagnosis, because she was already frail. Having worked on geriatric wards and with the elderly for most of her working life, Mum was very aware of the poor outcomes of resuscitation for the elderly and frail. She didn't want to go through that trauma.

I had to persuade my dad to agree to a DNR, in order for the medical repatriation company to bring him back to the UK when he became paralysed in Thailand. If he hadn't agreed and he had a heart attack mid flight, the plane would have to be diverted and land at one of the countries on its flight path. By the time he arrived at a hospital and was resuscitated, if successful, he would have suffered significant brain damage. The airline would not have agreed to him being taken on their plane without it, as he had a pulmonary embolism.

I am now 56 and already want to speak with my doctor about a DNR. However, after talking with my daughter, I will wait until my 60s. Nevertheless, I will ensure that it's done.

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Reply to MiaMoor

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FYI - POLST forms do not required a diagnosed disease or terminal illness. It will help make your end of life wishes known. Your doctor signs off on it. Check with your state for specifics.

Send your loved one to the Emergency Room with the POLST form.

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Reply to Silverspring

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That may depend on the state. As far as I know, in my state, POLST forms aren't valid unless the person has one or more serious life-limiting illnesses. Or at the very least, a doctor or nurse practitioner is not obligated to sign one if doing so would violate her or his ethical or religious beliefs. You might have to look around for a provider who is willing to sign one if your PCP is unwilling to do so.

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Often very old people are already in pain, and many have breathing difficulties. Unless a person (or their medical POA) has clearly requested that "everything be done", why add the damage and additional pain CPR often causes? IMO, in these situations CPR would very likely "do harm" and therefore would be a firm NO for me. I have stipulated comfort care only in my POLST and healthcare advance directive.

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Reply to ElizabethAR37

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It might be illegal in the absence of a DNR order. Even if the POA or other family members might not be able to be present (or reached by phone), they could sue the hospital or doctor(s). My husband's advanced directive said, in effect, "always do everything". If that had happened to him, you're darn tootin' that I would have sued even though he was in the advanced stages of frontotemporal degeneration (although he died young; 1 month and 8 days after his 66th birthday). I might have had to look for an attorney to take the case, but there are pro-life ones out there. I know I must face God someday and couldn't justify saying, "don't try; his life is useless". Hospitals and doctors cannot decide that a person is unworthy of (possibly) life-saving care because of her/his age or disability. This is a slippery slope that we go down at everyone's peril.

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Mia Moor,
But they're still alive. With time and the best medical care (which I assure you, I can afford), they may still improve. It's precisely what I'd want. No one can ever treat you as a throwaway unless you let them.

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Reply to swmckeown76

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Who says if one chooses to not be resuscitated one is a throwaway? I think it's a remarkably brave thing to do. To know there's an opportunity to leave the physical world and join one's loved ones in the spirit world would be a remarkable gift after years of painful body (and possibly mind) deterioration. I'm all for pulling the plug and so are my parents and hubby!

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There are folks who are terrified of dying and cannot imagine making the decision not to resuscitate. My daughter is a nurse and she has had patients who have zero quality of life...they can't eat, they can't walk, they are almost a hundred years old and have multiple incurable medical issues and they still want to be resuscitated. It's a personal decision that may not make sense to others.

Many of us pray to pass in our sleep so that these types of decisions don't have to be made.

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Reply to Jamesj

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I absolutely agree.
My brother had a hard time accepting our mum's decision to have a DNR in place. I thought that he would feel the same as me and Mum, so I wasn't prepared for how upset he was.
He would never make that decision himself, whereas I definitely will. He wouldn't want a plug pulled either, whereas I would rather not be hooked up to a machine in the first place.
I honestly can't understand anyone clinging onto life, when there's no quality to be had. And, I'd imagine, that someone who hates the thought of dying can't understand how it really doesn't scare me, and others like me.

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I think there was recently an article in the NY Times about this. The take away was that we all need to be aware that many many health professionals ignore (or don't see) a DNR order even if it's clearly posted in patient charts, posted on the fridge, in medical records with the PCP.

There are many disconnects that occur, example: the majority of EMT's after a 911 call will not honor a DNR while patient is in the ambulance. Their job is to get the patient alive to the hospital. The ER team may not have access to the DNR directive in a chaotic situation - they see their job as saving lives, period. The medical team involves a myriad of revolving staff- lots fall through the cracks with consistent attention to DNR's. Surgeons will not honor DNR's - their job is to keep patients alive during the surgery or their stats will go down. DNR's might be honored in recovery rooms after surgery, but it's a toss up.
So don't assume that DNR's will prevent the use of ventilators, feeding tubes, CPR, on a patient with clearly stated and legal DNR directives.
I plan to have DNR prominently tattooed on my chest. Not sure if even that would help.

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Reply to LostinPlace

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Wow! I did not know this!

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I have a POLST. The POLST is more detailed than a DNR it includes intubation, nutrition as well.
My sister is fully aware of my wishes as well.
It has always been my stance that CPR works great on TV, works great on reasonably young healthy people...not so much on older, weaker individuals with other medical conditions.
In general CPR will break ribs.
It may crack the sternum.
Ribs that are broken may puncture the lung.
Now that you have brought a broken body back from the brink of death how much brain damage has been done due to lack of circulation to the brain.
And can this already weakened body recover from broken bones, maybe a collapsed lung and now maybe more brain damage.
So my stance is no CPR on an elderly person with dementia or other life limiting conditions.
The best thing is to discuss this and the possible outcome with loved ones before it becomes an issue. And if nothing else make your wishes known.
A bit of advice though.
If you do complete a DNR or POLST Make several copies.
1. For your refrigerator.
2. Keep one in your car
3. Keep one in your purse or wallet
4. Make sure that your doctor is fully aware and that they have a copy in your medical record. (the doctor should be aware since a doctor has to sign the form.)
And it is a good idea to have each of these copies printed on bright colored paper so it stands out.
If you call 911 and the DNR or POLST is not available "it does not exist" until it is presented. And if the paramedics are called they will begin CPR if the form is not available.

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Reply to Grandma1954

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But the bones might heal, and is there not treatment (surgery?) for pierced lungs. If the person has clearly articulated that s/he doesn't want this tried, fine. But if not, why not? I can say with 100% certainty that I would.

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Reply to swmckeown76

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Yes bones heal. But they take a long time. The biggest problem with broken ribs is that you can not easily breathe. Add in collapsed lung and this is a recipe for pneumonia. If a person already has medical issues pneumonia can be fatal.
Then you add the fact that the brain may have not had oxygen for a while and brain damage may have occurred. Not in itself a big deal but if you are already talking about a person that has dementia as Fawnby has in her question this makes it much more difficult for the patient and caregivers. And there is probably no return to "baseline" if there is a recovery.
So...swmckeown76 make sure that your wishes are known. If a POLST is available (might go by other names in the State where you live) fill it out and indicate in each section what measures you want taken and there is a section in each if you want the treatment to continue or if it is for a period of time in case there is a recovery. But also please consider the worst case scenario what if you do not fully recover and are on a vent and tubes for the next 1, 3, 5 or more years do you want the end of your life to look like that?

When would you feel it’s the right time to enter a Do Not Resuscitate order for an elderly dementia patient?

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