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Features May 2014 Issue

Have You Thought About Giving a ‘Do Not Resuscitate’ Order?

Decision time if your dog goes into cardiopulmonary arrest.

Even the most casual viewer of primetime television hospital dramas has no doubt picked up that in many medical facilities, “Code Blue” means someone has gone into cardiac arrest — died on the table because her heart has stopped beating — and needs immediate assistance in the form of CPR to be brought back to life. In comes the crash cart. But at many veterinary hospitals, particularly at referral hospitals that have intensive care units such as the Foster Hospital at the Cummings School, any one of three color codes may be in order: Code Red, Code Yellow, or Code Green. And it’s up to you, the owner, to decide which it’s going to be.

It comes down to how aggressive you want the veterinary team’s efforts to become in working to save your dog should she stop breathing. “In many scenarios with people,” says Armelle de Laforcade, DVM, DACVECC, an emergency and critical care veterinarian whose daily work involves looking after dogs whose lives hang in the balance, “there’s a tendency to be as aggressive as you can no matter what. But if you have, say, an old dog with cancer whose quality of life is diminishing rapidly, you might feel, ‘How fair is CPR?’ It’s a lot to put a dog through if the quality of life you hope to return her to is no better than before — and will only get worse.” That is, with dogs, quality of life becomes at least as important as quantity of life. Even with people, oftentimes those who are very old and very, very sick, a “Do Not Resuscitate” order, or DNR, may be put in place, directing the hospital staff to let the patient go should her body give out rather than work to bring her back.

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Depending on the severity of your dog's condition should he have to stay in the hospital, you might want to think about whether to issue a DNR (Do Not Resuscitate) order.

That’s essentially what a Code Red is — a DNR. It means you do not wish to have CPR performed should your dog’s heart give out and she stops breathing. But how will your veterinarian know?

Having the discussion is critical

Talking about whether to try to resuscitate a dog “is kind of a hard conversation to have,” Dr. de Laforcade acknowledges, “similar to the way it would be for people. In asking people what their wishes are, or what their wishes are for their dog in the event of cardiac arrest, you’re letting them know, this could happen. And even though people are paying a lot of money, investing a lot both financially and emotionally to take care of a dog who at that point might already be very, very sick, they haven’t really come to terms with the fact that their pet could die.” Yet it’s important to think about this possibility — most certainly in an emergency situation, at any rate — so that your dog gets the level of treatment you want. “As someone who works in the emergency room,” Dr. de Laforcade comments, “I can say with confidence that things are very dynamic. The night’s very long.” That is, a lot could happen.

Granted, she says, “not everybody automatically knows what they should think if their pet is severely injured, or if the animal is really, really sick, what their decision would be in the event of a crisis. But that’s why it’s good to talk to your veterinarian beforehand. Having a vet help you make the decision is okay.”

For instance, she advises, “owners should work with their vet to understand why their pet might arrest and to get a sense of what the outcome is likely to be” if efforts are made to bring her back. “A healthy animal who has been hit by a car but was fine that morning — all the underlying organs were healthy — that’s a case where we may want to be aggressive because the animal’s chances of being resuscitated and going on to live an uncompromised life are actually pretty good. But if there’s significant underlying disease, like cancer, and the dog is already quite sick and goes into arrest, you might ask yourself, what are we trying to achieve here?”

Owners of some dogs for whom CPR has a relatively good chance of success may still opt for a Code Red — no effort to resuscitate their pet. They simply recoil at the idea or, literally, cannot afford it, and that’s okay. “Some people struggle to afford care to begin with,” Dr. de Laforcade says, and if their animal comes back to life with CPR, “it probably means a somewhat longer, somewhat more expensive, hospital stay, and an owner can very legitimately feel, ‘This is out of my league. I really can’t do this.’” It’s much better to make that decision in a clear-headed way in advance of the crisis, Dr. de Laforcade counsels, than to wade through the emotions and the (unnecessary) guilt and financial questions at a moment that there’s no time to lose.

On the flip side, some owners opt for a Code Green — which means acting as aggressively as possible about getting a dog back — even when the chances for reviving her, or returning her to a life worth living, are scant to nil. In such cases, the veterinarian will go as far as to make an incision in the chest to conduct internal cardiac massage. “You have the heart in your hand, and you’re squeezing to promote blood flow to vital organs like the brain,” Dr. de Laforcade says.

“The hardest situation for a veterinarian,” says Dr. de Laforcade, “is people saying they want CPR for a pet who should not have it. The person is struggling with saying good-bye” when the good-bye is imminent, even if the dog does survive the cardiac arrest.

Often the best option, which is the one she most often recommends, is a Code Yellow. That means the veterinarian starts CPR — giving drugs to try to make the heart start up again and beginning chest compressions to create some blood flow — and calling the owner. “For me as a criticalist,” she says, “in my perfect world, I start CPR, make an assessment of how likely it is to work, and then talk with the owner so she can make an informed decision about whether to proceed and, if so, how aggressively. The owner might ask, ‘Do you think we have a chance of getting her back?’ and I can say, ‘It looks like it might work’ or ‘We’ve already been at it for an extensive period of time….’ A yellow sticker on a dog’s cage because of a conversation before the crisis means that second conversation can take place and the owner can be an integral part of the decision-making.”

Does every hospital patient need a code?

If your dog is in the hospital but not in an Intensive Care Unit, it’s usually not critical to have a conversation with the veterinarian about what to do if she stops breathing. Chances are she’s there for something routine and will get through the hospital stay without a crisis. “But for those dogs who are admitted into intensive care or come in severely ill or physically traumatized,” Dr. de Laforcade says, “which code to use is worthwhile to have a conversation about so that everybody’s wishes are known. Animals in the ICU are the sickest ones in the hospital. They could have an event at any time. That’s why the ICU is staffed with doctors and nurses more intensively than any other part of the hospital — 24 hours a day.” In the event that a dog is in the ICU or an emergency room situation, she adds, the dog owner “should be reachable at any time day or night with a cell phone.” Especially in the case of a Code Yellow, communication becomes paramount. “Often, I’ll say, ‘the next 24 hours are very important,’” she explains. In other words, a very serious conversation may be imminent.

Truth be told, even the owner of a dog who comes in for a routine surgery should be available for a phone call from the vet. “We tell people that anesthesia is never 100 percent guaranteed,” says Dr. de Laforcade. Things almost always work out fine, but as with people, anesthesia presents risks and in rare cases, CPR may be needed. 

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