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Wednesday, August 8, 2012

BiPAP on DNR patients: an ethical issue

As with all ethical issues there really is no right or wrong answer.  The topic of the day is this:  Is it okay to use BiPAP on DNR patients?

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:

  1. 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.  
  2. 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 "NPPV Does Not Have a Positive Role to Play in the Care of DNR/DNI.

What's your take on this issue?


1 comment:

Aiesha Grant said...

As a student, I haven't strongly developed my stance on DNR/AND patients. But I do believe that BIPAP can be used on is non-invasive and while some feel that it is uncomfortable, some changes and adjustments in settings, mask etc can probably fix that right? Also, patients who are DNR and have a history of COPD have probably been on BIPAP many times before, (since high CO2 is an indication for using it) so discomfort may not be as big of an issue as some may think. (people get used to things over time). I am a firm believer in doing what the patient wants! I think that since this is an ethical issue, that NIPPV measures should be added to the list of questions when patients are asked about advanced directives. If the pt is conscious and able to speak for him or herself at the time, then that patient can specifically state whether or not NIPPV is ok. If not, then of course that is another issue! lol. I think that while healthcare members have the control of making that decision, every effort should be made to speak to the patient's next of kin, family members, etc. to at least get an idea of what that patient may have wanted for him or herself if the patient is unable to speak or has not provided written documentation indicating NIPPV measures are ok. It must be a difficult decision though because ultimately even though we have that control we need to remove our biases, beliefs, etc in order to truly do what is right for each patient!