Study Shows Do-Not-Resuscitate Orders Can Lead to Worse Care, Increase Death Rates

Transcript

Intro: I’m Dr. Nathaniel Chin, and you’re listening to Dementia Matters, a podcast about Alzheimer's disease. Dementia Matters is a production of the Wisconsin Alzheimer's Disease Research Center. Our goal is to educate listeners on the latest news in Alzheimer's disease research and caregiver strategies. Thanks for joining us.

Dr. Nathaniel Chin: Welcome back to Dementia Matters. Today I’m joined by Dr. Jonathan Baktari, CEO and chief medical officer of e7 Health, a preventive health and wellness company based in Nevada. Before launching a series of private health ventures, Dr. Baktari treated patients as a triple board-certified physician specializing in internal medicine, pulmonary and critical care medicine. In 2021, e7 Health released a study on Do-Not-Resuscitate, or DNR, orders in the American health care system. Analyzing peer-reviewed data from the CDC, American Heart Association, and Harvard Medical School over the past 20 years, the study found that the presence of DNR orders is increasingly connected to elevated death rates, poorer medical care, and other negative health outcomes. Today I’m going to talk with Dr. Baktari about these results in the context of Alzheimer’s disease and dementia. Dr. Baktari, welcome to Dementia Matters.

Baktari: Thank you so much for having me, what an honor. Thank you.

Chin: You launched e7 Health in 2009, and before then you were a physician seeing patients, leading in administrative roles, and teaching medical students. How did your experiences throughout your career bring you to where you are today?

Baktari: Well, you know it was a classic story of one door opening up another door. You know, just always trying to get involved in more things both administratively from quality control, from patient advocacy. It just appeared that as I progressed in my career, one door – yeah, you go through one door and then something else opens up and it was just a series of events that led me here so to speak.

Chin: Was DNR something of particular interest to you because of your clinical experience?

Baktari: Yeah, you know, rounding on ten to twenty ICU patients every day for many, many years, obviously it was, you know, a combination of DNR and we could talk about withdrawing life support and palliative care, which have some overlap but are somewhat different. Yeah, it became really important not only as a tool to prevent suffering but also honoring people's wishes in the right cases. Throughout that experience I did see a variation of how DNR was applied, how often it was applied. Part of that was the patient population. Just talking to my colleagues across the country – in certain parts of the country, institutional biases in terms of how to approach it, how often they use it. So when I talked to my colleagues across the country, there was a considerable discrepancy which was pretty noticeable.

Chin: And we're going to get into that too but to set the stage for our listeners, I want to ask some general questions for you. What does DNR actually mean and when is it used in healthcare?

Baktari: Right. So DNR, what it really means – of course it stands for do not resuscitate and I think it has really three components. Do not resuscitate applies to, initially, for example if your heart stops, in which case we would do CPR, a combination of CPR, what we call ACLS protocol, and potentially shock. Those three things happen essentially when your heart stops. Those have potential side effects as benefits, potentially, pnd so people need to understand what CPR involves, what it means, the risk of CPR, the risk of ACLS, you know, giving epinephrine and what have you, and following the ACLS protocol and other drugs, as well as shocking the heart if certain rhythms call for it. People need to understand what that is. That's one thing. The next thing is really intubation, which is putting an airway into someone's throat to breathe for them, the pros and cons of having that done and the benefits in certain situations. Lastly, using vasopressors, which is epinephrine or norepinephrine, levophed, all those medications that we give through a vein that often require a central line, hat have you. Classically, those are the things that fall under DNR and theoretically people can pick and choose out of those – you know, some people say, ‘Well, I don't want CPR and ACLS and shock. I don't want to be intubated, but I wouldn't mind having vasopressors,’ so there are combinations of that. That's CPR, which is really different than withdrawing life support and which is slightly different than palliative care. When DNR is applied – so I think it really broadly falls into two categories. Certain people choose DNR even when they're healthy. I've seen 30 year olds, 40 and 50 year olds just say, ‘Hey, I do not want these heroics in case I'm in a tough situation where there's very little hope.’ Then lastly you see it when patients come to the hospital and something catastrophic has happened, then the discussion is made with the patient, or sometimes, for example with dementia patients or patients who are just incapacitated, we have that discussion with significant others. So I think broadly speaking – although there's a middle road too – there are people who just don't want it but there are other people who don't want it once they get diagnosed with something, and so it's not always the same how you see a DNR status come to being.

Chin: And a Dnr order can always change, isn't that right, over time? Someone could stop or reverse a DNR decision?

Baktari: Yeah, right. You can withdraw the decision anytime. I mean in certain states there's this thing called DNR suspension so you can suspend DNR while you're having surgery theoretically in the pre- and post-operative period, but yes, by and large you can revoke it and you can restate it anytime you want.

Chin: And of course then, as a critical care doctor, can you have a DNR order while being in the ICU?

Baktari: Oh, clearly. I mean, because remember DNR in the most traditional sense is do not resuscitate me essentially if my heart or lungs stops, but you can get all sorts of care in the ICU which don't involve CPR or intubation.

Chin: I'm glad you answered it that way too because I'm trying to make the point, though, in order for a DNR order to be acted upon you actually have to die, right? Your heart has to stop beating and you have to stop breathing?

Baktari: Right. I think we're probably leading up to the rub where that's not often how it's interpreted, but in the most classic sense, yes it would only apply if your heart and lungs stop, which is different than palliative care where you direct, ‘I don't want – I don't want any kind of care or certain kind of care.’

Chin: Ok, so then despite what you've explained to us, having this DNR order is not really as straightforward as your explanation. There's evidence that hospitals administer fewer blood tests, IV, and routine procedures in individuals of DNR orders, which is not really a part of the order itself. So you and the e7 health team did a study analyzing DNR orders in US healthcare. What exactly did you find in this study?

Baktari: Well, you know, I can probably break it up into two kinds of, I don’t want to say shocking, but yeah, very cause for concern. One was simply the attitudes of healthcare workers. This is such an easy test to do. You could do it at the University of Wisconsin tomorrow. You just take 100 nurses or 100 doctors, give them a clinical situation where a patient presents with something and just mention on one – in an a and b version of the same scenario –  in the b version mention, ‘by the way the patient was DNR,’ and then list the whole series of things they offer the patient, a blood transfusion or surgical console. This is not something that is very hidden. Anyone can figure this out pretty quickly that the medical staff, including residents, attendings, and nurses, view DNR – not all of them, but there's a statistically significant – that they view DNR as some level of do not offer treatment or do not intervene in other things that have nothing to do with a DNR status. That's simply – I think you can't get away from that. That's true. In Wisconsin, it's probably true, in New York and Florida and what have you. There is a – how we got here is a more interesting discussion, but clearly the staff appears that there's a tendency for them not to offer things or even you know like if you're rounding on a patient and you're a subspecialist you say, ‘Oh well that person's DNR, I'll only round on him three times a week,’ so there's even subtle things. It's not even just if you have a busy day, who are you not going to round on? Again I'm talking about consultants, so you're the surgery consultant on a DNR patient who's following up on something. I think it takes many shapes and forms, so that's number one. Number two is actually looking at mortality. Some of these studies are pretty clear that there is, when everything else is factored in, that DNR patients sometimes have a higher mortality for elective procedures, for emergency surgeries, and just even just coming into the hospital for certain illnesses. I think, you know, when you factor in their health of DNR and non-DNR patients and age and all those other things, there still appears to be a discrepancy. Honestly we stopped after you know you know eight, nine, ten studies but we could have gone – the literature is just so full of it. It's actually – I think the issue is every study looks at stroke patients and another looks at elective surgeries, but if someone took all of those studies and put them together the pattern is indisputable.

Chin: And so I know your study didn't look specifically at people living with mild cognitive impairment or dementia, but how do you feel like these findings impact these individuals or people who have progressive conditions?

Baktari: Well, are you talking about people with cognitive dysfunctions in terms of their ability to make the decision or what happens to them after they make the decision?

Chin: Actually, I'd like you to answer both of those questions.

Baktari: Right. So I think obviously the ability to make the decision will be hampered because the solution we're coming up with is to be upfront and say, you know, if you become DNR and you have elective surgery or emergency surgery, you may not do as well if you're DNR so factor that into your decision. I think the ability for people to factor that into their decision obviously would be hampered by their ability to fully comprehend what that means. Then you'd be talking about, yeah, maybe potentially talking to their family, which means at the end of the day – I mean the more satellite-view question is, you know, does this mean we should get rid of DNR? Obviously DNR helps so many people that that's not the answer. The answer is to address a small subgroup of people who this impacts negatively. Although if you really look at DNR – if DNR was a drug or a medical procedure, it would be taken off the market. If, you know, if 10% of people who got the COVID vaccine died, the fact that it helps 90% of people is almost immaterial, right? If I came up with a new migraine medication that killed 2% of the people it took, I couldn't make the argument, ‘But it's helping 98% of people.’ So if it was simply a drug or a procedure and needed FDA approval, it would probably be taken off the market. I mean we have a different bar for DNR than we do for other stuff, but in all fairness that’s because it does really alleviate so much suffering. In the ninety whatever percent that it helps, I couldn't imagine those patients not having it and imagine the amount of pain and suffering we would cause in the end of life. So it's really – it's almost a philosophical philosophical issue because I don't think anyone can dispute that there's a subset of patients that are getting hurt by this, but I think those of us who've been in the trenches and have practiced clinical medicine for 20 years can't imagine going without it. It is kind of eye-opening to kind of step back and say, you know, we're hurting a significant subpopulation subset and so the answer is, you know, not to get rid of the drug, not to get rid of the procedure, but to figure out how we can address that subset that's getting hurt.

Chin: And so do you think that, in addressing that, is it a matter of culture change and education for healthcare providers? Also when I read your report, it made me think of the importance of advanced cure planning and talking to patients and their families in advance – well in advance, years ahead of time – to ask what is meaningful to you to make sure that they're really informed when they make decisions like this.

Baktari: Yeah, but the thing is, you really want to – if you really want to inform them, you have to come clean and say, ‘While this may benefit you and alleviate suffering and everything else, there's a small likelihood that this will also give you less care that's unrelated to your decision.’ Think of it almost like a side potential side effect of it. Just like when we give someone you know a medicine, say, ‘Well, there's a 10% chance this antibiotic will give you diarrhea. Can you live with that?’ So I think one is really informing them. I don't think we can say like if you make – if you really think about it hard these things won't happen to you. I think the real issue is on the clinical world, which is we have to make sure people understand that DNR does not mean do not treat.

Chin: I think that's the huge part of it and so does that – and certainly on the healthcare care side making sure that that is happening people are being treated. Do you think that also means that – I'm again putting on my geriatric hat and my memory care hat – that also means really empowering advocates and family members to speak for their loved ones who might not fully understand the situation and demands that care when they're?

Baktari: Right! I think you hit the nail on the head, to just say, ‘Hey just because my relative is DNR does not mean don't do the blood cultures, don't get a surgical consult, don't not round on him every day, you know?’ Again, I think we're that, of course, that's going to help but the real onus is on the medical world, but the real problem is not that. The real thing is people in the medical world don't recognize this problem. I mean I searched the literature to see if anyone else but us had connected all these dots, and there was one article I saw that, you know, kind of made it into the media – I think in the New York Post – a few years ago. Aside from that, the medical community does not acknowledge that it exists. I don't think they're hiding it. I just – the awareness is not there. If you approach – if you went to a medical conference and brought that up, I don't think you'd get a lot of heads shaking, ‘Oh yes, we've heard about this and this is an issue,’ so you can't begin to correct it. Medical schools can't begin to drum it into residents’ and medical students' heads if no one is discussing it and acknowledging that's a problem. So an opportunity to speak to your audience and other audiences is really helpful, but I think I can't – we can't just be, you know, just one person or one group of people bring it up. If we want to change, the medical community has to acknowledge that there is a perception problem that some people view DNR as do-not-treat or some level of do-not-treat.

Chin: So then what's next for e7 Health? What are you going to do with these powerful results? What is the next project for you?

Baktari: I think it's – I think, in fact, we're just about to do another podcast on this – which is really, I think in our first study we talked about the problem and I think focusing on, what we just talked about, the solution is, I think, our next level. It's all good and fine to point out a pattern. That's very obvious. Again, I want to reiterate, every study that we looked at, they all often referred to five other studies that corroborated what they were saying. We just got exhausted after that. There were so many more that if somebody literally – I don't know what the true number is, but there may be 100 peer-reviewed articles on this – that if anyone really put it all together, you know, it'd be very difficult to refute, but the question then becomes okay, let's now that we've established it let's be an advocate for a solution.

Chin: And so then now I'm gonna ask you to put on your care hat, so as a critical care physician you've seen people survive and pass away in the ICU. What do you want people to know about CPR and DNR orders?

Baktari: Well I mean let's talk about, let's say, you have a terminal illness and you know that CPR and do-not-resuscitate is unlikely to significantly change the course of your disease. People need to understand CPR is not without side effects. You know, often we break ribs when doing CPR; to the level that the person is conscious, it's painful potentially. Then when we do ACLS, you know, we give certain drugs which have side effects. They're not without side effects. When you shock someone, you know, I think people have seen that on TV where the paddles are taken out and the body sort of jumps up. These are not innocuous therapies, so clearly if they're futile and they're not going to impact the patient's eventual outcome – and study after study shows if you do CPR on someone with a malignancy in the hospital their chance of leaving the hospital is almost zero. So it can't – CPR and ACLS and shock and intubation, on some level, can be viewed as futile care where at best we're extending suffering and not extending life. This is why it's so beneficial for people to understand, and it goes to many other things. The statistics – and maybe you're more familiar with this – that, you know, people often spend two-thirds of their total life healthcare dollars within the last month or two of life. I think it goes to that because, at a certain point, we provide all this very aggressive care that's futile but we do it because the circumstances call for it. I think that's the first thing to realize. It's easy to kind of walk away from this interview and say, ‘Oh, DNR is bad.’ No, no, no. It's really amazing and it's – you wouldn't do open heart surgery on somebody who, you know, wouldn't benefit from it just because you can do it. I think it's important to understand that too. I want to be balanced. And intubation – you know, intubation has a lot of side effects. We can cause bearer trauma when we insert the ET tube. Being intubated requires often you be paralyzed or heavily sedated. There are complications associated with that. So DNR is not the kind of care where we just want to throw at someone and, you know, we have the technology. We have the technology to keep someone, theoretically, alive for weeks or months with absolutely no hope of them ever leaving the ICU or hospital, so I hope that puts it in perspective why DNR is so important, but the flip side is just because it's important doesn't mean we can't address that subset of population that is hurting.

Chin: What advice do you have for patients or family members of patients who were admitted to the hospital with DNR, at least things for them to think about?

Baktari: I think, what I would probably say – the advice that I didn't get to is, if people feel that they're being admitted to the hospital for a reason that doesn't connect to their original request to be DNR – so let's say, you have dementia and you want to be DNR and you get admitted because you have a ruptured appendix. One of the things that these studies pointed out is, let's say you have postoperative complications from a procedure that has nothing to do with the reason you were DNR, we see from these studies that people will not treat the natural postoperative complications of a procedure that has nothing to do with your DNR. So what I would say to especially people who don't have the cognitive awareness but certainly their families, to simply say, ‘Okay, you know, my relative is DNR but on this hospital stay I want to revoke it because this person's here for a ruptured appendix and that has nothing to do with whatever else.’ This is the part that families are going to have a hard time controlling, you know, especially post-procedure or what have you. Complications occur in a certain percentage of every moderate surgery and you don't want to fall in the category where you had a natural complication of the surgery, like for example sometimes when people, let's just say you know, appendicitis. They may have to go in a second time because, you know, the wound dehisced or something like that versus, you know, versus something that may not be offered to someone who's DNR. I think, from an advice point of view, just to realize that if you feel that something is going on, a hospitalization or a period within a hospitalization, that has nothing to do with the DNR status to either talk to your doctor or clinician and say, ‘No matter what happens, I want to be treated post-operatively for all these complications.’ And then once everything's resolved, maybe go back to your DNR status.

Chin: Well with that, I'd like to thank you for your time, Dr. Baktari, in explaining really important concepts for all of us regardless of our cognitive function. If another study – if you put on another study, we'd love to have you back on the show.

Baktari: Oh, thank you so much.

Outro: Thanks for listening to Dementia Matters. Be sure to follow us on Apple Podcasts, Spotify, Google Podcasts, or wherever you get your podcasts to be notified about upcoming episodes. You can also listen to our show by asking your smart speaker to play the Dementia Matters podcast. And please rate us on your favorite podcast app -- it helps other people find our show and lets us know how we are doing. Dementia Matters is brought to you by the Wisconsin Alzheimer's Disease Research Center. The Wisconsin Alzheimer's Disease Research Center combines academic, clinical, and research expertise from the University of Wisconsin School of Medicine and Public Health and the Geriatric Research Education and Clinical Center of the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin. It receives funding from private university, state, and national sources, including a grant from the National Institutes of Health for Alzheimer's Disease Centers. This episode of Dementia Matters was produced by Rebecca Wasieleski and edited by Caoilfhinn Rauwerdink. Our musical jingle is "Cases to Rest" by Blue Dot Sessions. To learn more about the Wisconsin Alzheimer's Disease Research Center and Dementia Matters, check out our website at adrc.wisc.edu. You can also follow our Facebook page at Wisconsin Alzheimer’s Disease Research Center and our Twitter @wisconsinadrc. If you have any questions or comments, email us at dementiamatters@medicine.wisc.edu. Thanks for listening.