Post 60: What Does a DNR Do if Only My Lungs Are in Trouble?
Updated: Nov 2, 2022
Sometimes people ask, “What happens if I don’t want CPR, breathing tube, or machines if my heart stops, but I'm okay with the breathing tube and whatever it takes for me to get through a bad pneumonia?”
The default mode among the medical community is to try to resuscitate, or revive, someone's heart and lungs when the heart and lungs stop. This entails CPR (cardiopulmonary resuscitation) which includes chest compressions and possibly shocks from defibrillating paddles in an attempt to get the heart beating again, as well as a breathing tube placement (intubation) so that the breathing machine (ventilator) can "breathe" for the lungs. The hope would be that the lungs would be able to function on their own, and the breathing tube eventually removed. Resuscitation attempts cannot include only chest compressions without the breathing machine because if heart and lungs stop, you would want to revive both heart and lungs (read Post 5: CPR on TV versus CPR in Real Life - Three Ways They Differ).
If someone says they wish for a natural death - "Let my body be if my heart stops!" - and that they would not want resuscitation attempts, they are saying they would not want CPR attempts nor breathing tube or machines if/when their heart and lungs were to stop. This wish is called a DNR (Do Not Resuscitate) or DNAR (Do Not Attempt Resuscitation) in the medical community (read Post 6: Who Do I Tell if My Mom Does Not Want Resuscitation Attempts? - A Three Step Process). Some hospitals call this wish an AND (Allow Natural Death).
In this post, I talk about the person with lung, respiratory, pulmonary, or breathing issues, such as asthma, who may more easily deteriorate into respiratory failure - that is, the lungs are no longer able to work on their own - with even fixable causes such as a treatable pneumonia. Healthcare providers may say, "We can turn this around. We'll buy time for your lungs to recover by helping your lungs breathe with the ventilator. We will give antibiotics for the infection and diuretics for the fluid in the lungs. Your lungs should improve, and we should be able to get you off the ventilator." (Note, a ventilator is the same as a "breathing machine" or "life support machine.")
For this reason, some people with severe respiratory issues or advanced lung disease who express DNR (Do Not Resuscitate) wishes may explicitly remind their family and healthcare providers that they would choose to be intubated and connected to a ventilator if only their lungs ran into trouble and they continued to have a pulse. "I don't want to be put through all that if my heart stops. If I'm gone, I'm gone. But if my heart is still beating, and I'm having trouble breathing, keep me going!"
Out of Hospital DNR forms should not affect one's medical care as long as the heart is beating. If someone has severe pneumonia and is struggling to maintain their oxygen levels or gasping for air - and is clearly alive with a beating heart - they should automatically receive all the intensive respiratory care, even ICU level of care, that a person without a DNR form would receive [in Post 21: When Should a Person Consider Tearing Up Their Out of Hospital Do Not Resuscitate (DNR) Form?, I talk about revoking your DNR form if you ever thought this document were preventing you from receiving the level of medical care you desired].
In reality, depending on the severity of their medical issues, the state of their health and strength, their overall prognosis, and their goals of care, some people with DNR wishes would want intubation for severe breathing difficulties and others would not.
Your loved ones and your healthcare providers would only know your thoughts on the matter if you relayed your wishes. If you did not, likely the default mode to place a breathing tube would occur. Whatever your thoughts may be on the matter, communicate them to your family - especially to your medical power of attorney [read Post 4 - Eleven Common Myths about the Medical Power of Attorney (MPOA)] - and then again, if you were to change your mind.
Sometimes doctors express their worries that a person's lung disease is so severe that it would be difficult, even unlikely, that they would be able to stabilize this person's breathing off the ventilator if their lung functioning were to deteriorate to the point of requiring ventilator assistance. "Your COPD is very severe. I'm worried that if we intubate you - meaning, we put the breathing tube in and connect you to the breathing machine - we may not be able to get you off the breathing machine, which we call the ventilator. We need to talk about your priorities and goals of care and what you consider quality of life, so we can together make the best plan on what to do next."
In these cases, some people might say that they would want to completely avoid intubation, accepting at most noninvasive forms of respiratory support (meaning, breathing equipment that do not go into the airway) such as CPAP (continuous positive airway pressure). With noninvasive forms of breathing support, one would wear a mask over the nose or nose and mouth instead of having a breathing tube placed inside their mouth and airway. Air pressure is pushed through this particular type of mask to keep one's airways open. A person who uses these forms of noninvasive breathing support must remain alert enough to breathe on their own.
[If a person with respiratory failure had difficulty using CPAP, which pushes one pressure level of air, they could be switched to BIPAP (bilevel positive airway pressure), which pushes a greater pressure of air during inhalation and a smaller pressure of air during exhalation, making it easier to exhale "against" the pressure. There are other types of specialized noninvasive respiratory equipment that could potentially be attempted in certain situations.]
The hope would be that the noninvasive forms would be adequate to buy a person's lungs time to recover from their acute illness and start working independently again.
Sometimes, however, a loved one's lung functioning does worsen or the loved one loses alertness. If they had already clearly expressed wishes against intubation, this would normally be the time for family and healthcare providers to honor their loved one's wishes and focus on providing comfort and minimizing symptoms of breathlessness with medications. These would be the new goals of their loved one's medical care until their loved one died from respiratory failure (read Post 38: Choosing Where, When, and How a Loved One Dies Takes Knowledge, Action, and Courage).
Of course, this shift of thinking is often very difficult for family members. Therefore, if you as the patient had clear preferences on how you yourself would choose to make certain medical decisions that you suspect may be emotionally hard for your family members to contemplate, then the best thing you could do to attempt to reassure your close family and friends and increase the chances that your wishes would be honored is to talk about them with your close family and friends.
I hope this post provides some clarity about a commonly asked question regarding advance directives for those living with chronic respiratory, pulmonary, breathing, or lung issues. This topic is not easy to bring up - so as with many aspects of life, it is a matter of weighing potential future regret over not discussing these matters against the awkwardness in bringing them up now when you have the time and space to discuss them in a non-urgent manner. I do provide suggestions on how you could bring up advance directives in Post 19: Bringing Up Medical Power of Attorney (MPOA) Doesn't Have to Be Awkward - A Six Step Guide, which I hope are helpful for future conversations.