Do not resuscitate

[SteveK]

Hi guys.

 

It is well known in the UK that you can have a DNR (do not resuscitate) order placed into your medical notes through your doctor. This means that if your heart stops they don't start zapping you or trying to do CPR. As well as having this added to your medical records, people can also wear a DNR necklace or have a DNR tattoo on the inside of their wrist.

 

My question is, would this be understood in Thailand? I have told my wife about this but am contemplating getting a tattoo, but if they ignore it, it will be a waste of time.

 

Thanks.

[scubascuba3]

I've wondered this myself. Maybe better to tattoo on you "i have no money, you will not be paid if you resuscitate me, so don't, thank you"

[PPMMUU]

Yes, it does. The concept of palliative care (including no resuscitation order) is widely well understood (in the medical personnal, that is).

 

A written document is always a good idea though.

[Sheryl]

A tattoo is certainly of no use here. You can make a legally binding Advance Directive under Thai law. Note that many hospitals want it to be on their own form (though I think they could be legally held to any form that follows Thai law).

 

 

[Speedo1968]

Following a serious lung infection in 2012 which was not responding to antibiotics ( except as an allergic response ) but did respond well to an alternative therapy, I drew up and placed a DNR request with the hospitals I visit, I check regularly that it is still on file.     

 

Secondly, when out I always carry a copy with me and include with that a list of medications that I am allergic to, for example antibiotics, high risk medications of any kind are in red type, the date of first bad response is also noted as well the kind of response to the medication.   Also alternative therapies that may be used ( having proved beneficial in the past (( and did also in this particular circumstance )).  With the alternative therapies the doctors would only permit once I was conscious.  A copy of this is also with the hospitals concerned.     Along with this are copies of my hospital numbers.

 

Thirdly I have the same documents in clear view in my house and at least one person is aware of this.

 

Finally - all such documents are with family in the UK.

 

About 4 years ago at my house I had a major stroke complicated by rhabdomyolysis and ARF.    The documents were shown to the ambulance crew and again to the doctors at the hospital, they crosschecked with the files on record and accepted my requests.

 

It sounds a lot of documents but folded up take little space and could aid the decision makers whether they be family, friends or the hospitals concerned.

 

 

 

[1FinickyOne]

My elderly aunt was in a nursing home. She wanted to die... we had an agreement that she would not have to leave to go to the hospital under any circumstances... and yet, the nurse could not let that stand and in her dying day she was sent to the hospital... then I had to have a conversation w/a doctor who told me he could work miracles to save her life... and I had to have the guilt of telling him - let her go home and die... 

 

contracts/written agreements/ aren't always reality. 

[fittobethaied]

Living Will in English and Thai from Bangkok Hospital:

living will form Eng and Thai.pdf Thai Living Will Sample.docx

[Tropposurfer]

As stated DNA is a world wide medically recognised concept and human right ... it transcends borders and quasi religious/social attitudes. Upon moving here I had 2 dogtags made at a local night market.

One has name address next of kin phone.

The other has blood group, nil allergies, and DNA.

I also carry a laminated card in my wallet next to my insurance card with blood type, organ donation authority (I’m registered on my insurers database as wanting my organs harvested as well), and DNA on it along with my signature.

 

[Sheryl]

15 minutes ago, Tropposurfer said:

As stated DNA is a world wide medically recognised concept and human right ... it transcends borders and quasi religious/social attitudes. Upon moving here I had 2 dogtags made at a local night market.

One has name address next of kin phone.

The other has blood group, nil allergies, and DNA.

I also carry a laminated card in my wallet next to my insurance card with blood type, organ donation authority (I’m registered on my insurers database as wanting my organs harvested as well), and DNA on it along with my signature.

 

It is NOT recognized worldwide. Only some countries have laws recognizing it.

 

Thailand only fairly recently enacted such  legislation  and there are prescribed procedures to follow. A laminated card won't do it.

 

You need to execute an Advanced Directive (AKA living will) in accordance with Thai law and most importantly should execute a health care power of attorney and make sure the person who you name has copies of your Advance Directive and is prepared to advocate on your behalf.

[Gilltom]

16 hours ago, PPMMUU said:

Yes, it does. The concept of palliative care (including no resuscitation order) is widely well understood (in the medical personnal, that is).

 

A written document is always a good idea though.

Yes it does my friend had on his medical record at hos and they adhered by it 

[007 RED]

Please bear in mind that having a DNR instructions logged with your hospital, or having a DNR tattoo/bracelet, is not going to stop the first responders/rescue doing CPR (and possibly using an AED) on you if you collapse in a public area (street/shopping mall etc) or if you are involved in a serious accident and do not have a pulse when they arrive.

 

Sorry, but unfortunately Thai first responders/rescue are not aware of DNR means.

[OneMoreFarang]

It seems the main reason for the existence of private Thai hospitals is to make money - as much as possible.

That makes it unlikely that they will let anybody die who is supposed to pay them.

 

[OneMoreFarang]

2 hours ago, kenk24 said:

My elderly aunt was in a nursing home. She wanted to die... we had an agreement that she would not have to leave to go to the hospital under any circumstances... and yet, the nurse could not let that stand and in her dying day she was sent to the hospital... then I had to have a conversation w/a doctor who told me he could work miracles to save her life... and I had to have the guilt of telling him - let her go home and die... 

 

contracts/written agreements/ aren't always reality. 

I guess one of the problems is the Hippocratic Oath. As far as I know doctors make the oath to save lives. 

[Max69xl]

Is this really a problem? Oh, I died, but they zapped me by mistake and I survived. 

[sanuk711]

I copied this some time ago---if the mods feel it is to long...then apologies please delete.

 

How Doctors Die

It’s Not Like the Rest of Us, But It Should Be

 

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

 

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.

 

To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.

How has it come to this—that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.

 

To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.

 

The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax”), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.

But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.

 

Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.

Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.

 

It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.

Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.

But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.

 

Several years ago, my older cousin Torch (born at home by the light of a flashlight—or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.

We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.

 

Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.

[elgenon]

18 hours ago, scubascuba3 said:

I've wondered this myself. Maybe better to tattoo on you "i have no money, you will not be paid if you resuscitate me, so don't, thank you"

I was thinking of getting a tattoo with my credit card info in case the people picking me up off the sidewalk borrowed my credit card.

[cooked]

I know of many Thais that elected to return home to die, more than I do of those that stayed in the hospital to the great inconvenience of whoever was looking after them.

Our neighbour, ambulance driver, knew what was likely to happen and died at home, I was there. We had a doctor coming by once a day to give pain killer. no big deal really.

By the way half the village turned out to at least get the roof on his new house so that he could experience that, he was able to help a little. This isn't a nanny state, no bureaucrat was deciding for him if he could go home or not.

 

[KKr]

18 hours ago, Sheryl said:

A tattoo is certainly of no use here. You can make a legally binding Advance Directive under Thai law. Note that many hospitals want it to be on their own form (though I think they could be legally held to any form that follows Thai law).

 

 

Indeed.
In my opinion the Advance Directive should better be Notarised and must have the prescribed number of witnesses.
This will avoid confusion in case, and thus not expose relatives to additional stress.

[DefaultName]

This may seem cynical, but it isn't meant that way.

Just tell the doctors that you won't pay.  In most countries they would still try, but here?

 

I can see the day when I will need to go, when it happens, I hope I can do it quietly at home with family, not with a bunch of tubes sticking out of me, among strangers.

[emptypockets]

16 hours ago, Speedo1968 said:

Following a serious lung infection in 2012 which was not responding to antibiotics ( except as an allergic response ) but did respond well to an alternative therapy, I drew up and placed a DNR request with the hospitals I visit, I check regularly that it is still on file.     

 

Secondly, when out I always carry a copy with me and include with that a list of medications that I am allergic to, for example antibiotics, high risk medications of any kind are in red type, the date of first bad response is also noted as well the kind of response to the medication.   Also alternative therapies that may be used ( having proved beneficial in the past (( and did also in this particular circumstance )).  With the alternative therapies the doctors would only permit once I was conscious.  A copy of this is also with the hospitals concerned.     Along with this are copies of my hospital numbers.

 

Thirdly I have the same documents in clear view in my house and at least one person is aware of this.

 

Finally - all such documents are with family in the UK.

 

About 4 years ago at my house I had a major stroke complicated by rhabdomyolysis and ARF.    The documents were shown to the ambulance crew and again to the doctors at the hospital, they crosschecked with the files on record and accepted my requests.

 

It sounds a lot of documents but folded up take little space and could aid the decision makers whether they be family, friends or the hospitals concerned.

 

 

 

All translated in to Thai? And kept at one or more Thai hospitals?

[Moonlover]

1 hour ago, Max69xl said:

Is this really a problem? Oh, I died, but they zapped me by mistake and I survived. 

Yes this is a problem and your flippant response is not helpful.

 

If by being resuscitated means returning to life as normal, then indeed no problem. But life is rarely that simple. If I was resuscitated and the result was that my future life would be grossly inhibited, especially mentally, I would not want to know.

 

Being totally helpless would be abhorrent to me. Let me die.

 

Edited March 17, 2020 by Moonlover

[Tropicalevo]

To the OP.

Thank you for raising this one. I now know the way forward.

[tweedledee2]

4 hours ago, kenk24 said:

My elderly aunt was in a nursing home. She wanted to die... we had an agreement that she would not have to leave to go to the hospital under any circumstances... and yet, the nurse could not let that stand and in her dying day she was sent to the hospital... then I had to have a conversation w/a doctor who told me he could work miracles to save her life... and I had to have the guilt of telling him - let her go home and die... 

 

contracts/written agreements/ aren't always reality. 

I once worked as a Medic for a hospital based ACLS ambulance service. Within our service area we had 3 nursing homes, 2 assisted living centers, 1 privately owned retirement home for women and a state Veteran's home. Of those facilities, 2 of the 3 nursing homes always requested ambulance transport to the hospital for their terminally ill patients, no matter what the patients advanced directive or the family had requested. Having the resident die at the hospital meant they didn't have to report the death and kept their on site death rate statistics lower.

[khunPer]

20 hours ago, scubascuba3 said:

I've wondered this myself. Maybe better to tattoo on you "i have no money, you will not be paid if you resuscitate me, so don't, thank you"

Should probably be translated to Thai and translation double-checked before tattooed in a couple vital places, eventually together with the English text, so the information would not be missed...????

Edited March 17, 2020 by khunPer

[xylophone]

I had a friend here who had severe cirrhosis of the liver, causing ascites and internal bleeding, and I and his partner here on many occasions, sometimes in the early hours of the morning, took him to hospital and he was in ICU for many days at a time.

 

He also had internal bleeding elsewhere and the hospital had to use some very expensive medications on him for days at a time, and the cost was anywhere between 500,000 baht and 1.4 million baht.

 

I had long discussions with him and his doctor, and of course his partner, and the doctor warned him that he had to stop drinking, but he wouldn't and these events continued until one day the doctor called just me and his partner into the room, and we discussed that when he next came into hospital, that nature would take its course and he would be given just normal medications, and he noted that in the files.

 

That wasn't actually necessary because a couple of months later he died in an ambulance on the way to hospital.

 

One thing that came out of this was that the doctor was adamant that if the patient wasn't going to do anything to help himself, and also ease to the burden on his partner and me (his carer to all intents and purposes) then continually bringing him into hospital was wasting valuable time and resources – – quite a statement from a Thai doctor, but I respected him for it.
 

 

[1FinickyOne]

5 hours ago, OneMoreFarang said:

I guess one of the problems is the Hippocratic Oath. As far as I know doctors make the oath to save lives. 

I thought the oath was to do no harm??... I'll have to check that... and in the case of my aunt, they would not have been saving her life so much as prolonging her discomfort... she had made a specific request not to return to a hospital... I understand that it upset the night nurse to see her dying... 

[1FinickyOne]

3 hours ago, tweedledee2 said:

I once worked as a Medic for a hospital based ACLS ambulance service. Within our service area we had 3 nursing homes, 2 assisted living centers, 1 privately owned retirement home for women and a state Veteran's home. Of those facilities, 2 of the 3 nursing homes always requested ambulance transport to the hospital for their terminally ill patients, no matter what the patients advanced directive or the family had requested. Having the resident die at the hospital meant they didn't have to report the death and kept their on site death rate statistics lower.

my aunt was blind, crippled and frail... she was sent [at age 90] by the home to a hospital and the witch owner of the assisted living home, told her she could not come back which threw her into a total panic attack [she couldn't breathe] as she felt she was going to be thrown in the street... this was the last thing she needed and we got her back in w/a directive to let her die there... thanks for enlightening me as to the negative stat for the nursing home... 

[Just Weird]

6 hours ago, Sheryl said:

6 hours ago, Tropposurfer said:

As stated DNA is a world wide medically recognised concept and human right ... it transcends borders and quasi religious/social attitudes. Upon moving here I had 2 dogtags made at a local night market.

One has name address next of kin phone.

The other has blood group, nil allergies, and DNA.

I also carry a laminated card in my wallet next to my insurance card with blood type, organ donation authority (I’m registered on my insurers database as wanting my organs harvested as well), and DNA on it along with my signature.

 

It is NOT recognized worldwide. Only some countries have laws recognizing it.

 

I think you'll find that DNA and it's science, which is what he posted, is, in fact, recognised worldwide.

Edited March 17, 2020 by Just Weird

[Sheryl]

He obvioisly meant DNR

[tweedledee2]

1 hour ago, Just Weird said:

I think you'll find that DNA and it's science, which is what he posted, is, in fact, recognised worldwide.

Either the poster mistakenly used the acronym DNA when typing his post instead of DNR (DO NOT RESUSCITATE) or his ID tags do have the letters "DNA" stamped on them, which would be meaningless to medical providers trying to sustain his life.