Friday, February 26, 2016

Do You Want “Do Not Resuscitate” (DNR) on Your Medical Record?

Do you want to be “do not resuscitate?” Do you want to be DNR? If you are admitted to the hospital, they may talk to you about advanced directives, a living will, or a durable power of attorney for healthcare. These things vary from state to state. One of the things you may have to figure out is whether you want a "do not resuscitate" (DNR) order on your chart or not.

What is the evidence-based medicine for survival after CPR in the hospital? We need to know the Treatment Score. For patients who undergo CPR and resuscitation in the hospital, do they survive 1% of the time or 100% of the time? Do you have any idea?

The Treatment Score for CPR plus resuscitation in the hospital is very important. It is life and death for you to figure out if you want to be labeled “do not resuscitate.”

In order for patients to figure DNR out, they need to know the Treatment Scores for surviving a “code blue.” Patients need the most information possible presented in the most understandable way possible.

Cardiac Arrest in the Hospital

Let’s look at three scenarios. Let’s look at cardiac arrest in the hospital at a level I trauma center and look at survival to discharge for all the patients. Second let’s look at cardiac arrest in the hospital with a Dartmouth Score of 7 or lower. Third, let’s look at cardiac in the hospital with a Dartmouth Score of 9 or higher.

The Dartmouth Score is a clinical prediction rule. The Dartmouth Score takes into account the presence or absence of the following things: age, chest pain, dementia, respiratory insufficiency, stroke, hypotension, abnormal oxygenation, abnormal bicarbonate levels, coma, and cancer. The lower the Dartmouth Score is the better your overall health. Our three diagnoses are in the graphic below.





The Treatment Score for surviving to hospital discharge for all patients is 25.7, which is on a 100-point scale, so it is the same as 25.7%. I wasn’t sure what the Treatment Score would be when I started this project: it's nice to see some quantification. So, about one fourth of the patients survive cardiac arrest, CPR, and resuscitation to be discharged from the hospital. The unknown is how good of health they are in when they are discharged.

Let’s look at the Treatment Score Calculator as a graphic below. The main statistic is survival to hospital discharge, which goes on the left. The side effects and side benefits go on the right. Unfortunately, I could not find usable data for the side effects and side benefits of undergoing CPR + resuscitation in the hospital. 

The big question is, when such patients are discharged from the hospital are they “vegetables?” Or are they neurologically intact? Or are they somewhere in between. Are they better off health-wise than before going into the hospital? So, because of missing data, I consider the Treatment Score of 25.7 to be more of a gross number than the net number we usually try to produce.




Dartmouth Score of 7 or Lower

Let’s look at patients with a Dartmouth Score of 7 or lower. The lower Dartmouth Score means that these patients are in better health. The diagnosis is in the graphic below.


The Treatment Score in this situation = 35. That's much higher! That means 35% of these patients survive to hospital discharge. Again, however the question is what shape are these patients in? Are they impaired? Are they neurologically intact? Or are they somewhere in between? Could they be even healthier than before hospitalization? The Treatment Score calculator for this situation is below.


  

Dartmouth Score of 9 or Higher

Now let’s look at how the Treatment Score changes when patients have a Dartmouth Score of 9 or higher. These are a sicker group of patients and that’s why they have a higher Dartmouth Score. The diagnosis in this situation looks like the graphic below. 



The Treatment Score in this situation = 12. That’s 12% survival to discharge from the hospital. Again, the problem is we don’t know their status at discharge. Are they better off or worse off than before they went in the hospital? The Treatment Score Calculator for this situation is below. Once again, we do not have good enough information on the side effects and side benefits of treatment (if there are any). We don’t know enough about their neurological status and we don’t know enough about their overall health. Is their health better at discharge or worse at discharge?




The Future of Medicine

What I am showing you is the future of medicine. In the future we are no longer going to say, “Here is a list of treatments, which one do you want?” We are going to give you a list of treatments and Treatment Scores. It will be like this:

Diagnosis: Cardiac arrest, in hospital, level I trauma center 
Treatment Score = 25.7

Diagnosis: cardiac arrest, in hospital, level I trauma center, Dartmouth Score 7 or lower
Treatment Score = 35

Diagnosis: cardiac arrest, in hospital, level I trauma center, Dartmouth Score of 9 or higher
Treatment Score = 12

In the future, Treatment Scores are going to be personalized to you as much as possible. We are also going to explain to you the missing data. 

To empower patients, we must begin to organize and quantify the data into Treatment Scores. It’s no longer good enough to tell patients what to do, we must let them understand their options with shared decision-making and evidence-based medicine. (See the disclaimers below.)

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You must consult your own licensed physician, or other licensed medical professional, for diagnosis, treatment, and for the interpretation of all medical statistics including Treatment Scores. Treatment Scores are for educational purposes only. Treatment Scores may be incomplete, inaccurate, harmful, or even cause death if used for treatment instead of consulting a licensed medical professional. No medical advice is being given. We DO NOT CLAIM to cure, treat, or prevent any illness or condition. Nor do our services provide medical advice or constitute a physician patient relationship. Contact a physician or other medical professional if you suspect that you are ill. Call emergency services (call 911 if available) or go to the nearest emergency room if an emergency is suspected. We are not responsible for any delays in care from using our website, our services, or for any other reason. We are not responsible for any consequential damages of any nature whatsoever. We make no warranties of any kind in connection with our writings or the use of TreatmentScoresBlog.com or TreatmentScores.com. Treatment Scores are about what happened to patients studied in the past; they do not predict the future.

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