Argument #1: BiPAP should not be used on DNR patients. A perspective from Dr. Marjorie Olson:
If a patient declares a DNR status, she is basically saying she wants to die naturally. She wants to spend the last moments of her life without an uncomfortable tube in her throat, and an uncomfortable mask over her face. I think to place a BiPAP on such a patient would be unethical.Argument #2: BiPAP is an option for DNR patients. A perspective from Dr. Apple:
Just because someone has declared DNR status does not mean we don't treat. BiPAP is non-invasive procedure that can help a spontaneously breathing and compliant patient get over the hump.Argument #3: BiPAP can be used if the patient is already prescribed it, and is fine with wearing it. Then it is okay to use BiPAP at any time during the DNR status.
Argument #4: Anytime the patient is fine with trialing a BiPAP it is okay to use it. If you explain it to the patient and she's willing to try it, especially if it will make her more comfortable, then it's okay to use BiPAP on a DNR patient.
Still, it's not that easy. Allow me to ask the following questions:
- What if the patient is breathing is in renal failure, her SpO2 is 80-88% and falling, her pH is 7.20, and she is getting increasingly weaker. She is in chronic pain. Do you put a BiPAP mask on her. She is not labored and denies breathing difficulty.
- Given the above situation, you are a doctor who believes in either of the above arguments, and the family insists something be done. Do you use BiPAP then?
Again, there is no right or wrong answer. My opinion is if you actually think you can pull the patient over the hump, go for it. However, if it was your grandma in that bed, would you want her to have to deal with an uncomfortable, tight, hot, stuffy, claustrophobic mask over her face?
For question number one above, I think this would be the classic patient to allow her to spend the last moments of her life without a mask over her face. However, in the case we had today, Dr. Apple opted to give in to the request of the husband who wanted to do something.
Jeff Whitnack, RRT, wrote an article on this issue over at rtmagazine.com: "NPPV Does Not Have a Positive Role to Play in the Care of DNR/DNI.
What's your take on this issue?