If this was me I would want a DNR and a DNI signed. More importantly, I would want a MOLST form singed indicating exactly the care that I would want, the care that I don't want, and for how long. That is to say, give me antibiotics for one week and see how I do, if nothing's happening then stop all unnecessary treatments.What I like to see in patients is an end goal. What happens far too often, is patients will sit in an ICU for an extended period of time deconditioning and not getting better, but family does not want to do anything for fear of making the situation worse or feeling like they are murdering a family member by taking away care. Recognize that his pancreas is not well at all. His kidneys are not well at all. His liver is not well at all. Assumedly, his lungs aren't either.Let's say he is extubated. Now we have a burnt pancreas. And kidney. And liver. If you are this young and have liver dysfunction or failure, that's a life of slowly getting sicker and sicker until you can possibly but probably not get a liver transplant in the future. It's painful. If his kidneys are truly shot and he requires dialysis in the future, that's 50 years of spending 3 days a week going to get dialysis and sitting there having your blood cycled over and over for hours, just to go home and not feel well. Then you do it again. Then you do it again. That's a lot of stress for a 30-year-old. A 30-year-old that already has alcoholism. If your pancreas is constantly becoming inflamed, diabetes maybe in the future or at least insulin dependence. A 30-year-old diabetic will have a low quality of life.DNR and DNIs are to preserve a patient's dignity thinking about the long-term consequences to their health and quality of life. The idea that saving people is enough, is not enough. By stating do not resuscitate, You're saying to give a chance, but don't take it farther than he would like given all that has happened, and will happen in the future.The doctor sees this all the time. The doctor sees a family that holds on to hope that everything will be okay because their family member is " a fighter, " but neglects to see that the patient has already fought 25 rounds and has been knocked out three times. And also neglects to see that, if they come out of the fight, they essentially will have an agonizing future for the rest of their life.
To clarify, just because the organs aren't necrotic doesn't mean they are functioning. Also organ donation has nothing to do with DNR. The appropriateness of someone to donate only comes after they have died or are literally about to. In the US people self-declare at the DMV so the organ donation services already know their intent in most cases.He has multisystem organ failure, plus underlying conditions which will make his recovery harder than someone without those (alcoholism, solitary kidney) based on what you have written, so it is absolutely imperative to find out what his wishes might be regarding code status. In the absence of any clear directives from the patient in the past, the family is asked to predict what the patient would choose for themself if they were able to sit in on the discussion and weigh in--basing this off of past comments, how they engaged (or avoided) healthcare interventions on their own, etc.I suggest that his designated healthcare agent and any other family present, have a care conference with the intensivist. This is a time set aside in a nearby conference room, not at the bedside or in the hall. Include one of his nurses if possible, any specialists who can make it (often harder to arrange) and then the unit's social worker/case manager. The purpose is to outline exactly where he is on his trajectory, what the major challenges are, what the expected chances of recovery appear to be at this point, and then a discussion of next steps. Find out more about why the doctor was recommending DNR. Hear what they have to say about this based on their experience. It might be because they don't feel he will likely be resuscitated if they make attempts, therefore, to attempt shocks and compressions would be futile. If they feel it would be futile, then it would represent only harm to the patient and not comfort or cure. I cannot predict what they are thinking so you need to find out, but this has been my experience from working in ICU as an RN and Care Manager.If he cannot be weaned off of the vent shortly, he will need a trach and a PEG (feeding tube in his side). If he stabilizes enough to be discharged from ICU (off of CRRT, off of high vent settings, off of any vasopressors that are stabilizing his BP, only on X number of antibiotics, etc) then he will meet criteria to transfer to a ventilator rehabilitation hospital or LTACH (long term acute care hospital).If this happens, it is a long slog. Is it something he would want? Also, he might not survive it and could have a downturn at any time, heading back to the hospital. Knowing this, is this something the family would predict HE would want? If so, you have your answer. If not, then it is appropriate to consult hospice to make him comfortable. Another service to consult if you have it available is Palliative Care. In many hospitals they are consulted for complex cases like this who are taking a long time to recover. They are particularly helpful to the patient to improve quality of life while recovering, as well as provide support and guidance to family.At the end of this long post, I offer you two things. One-you are in my thoughts. I know how difficult this is and you are on a crash course of learning right now. Two, please use this resource that many families in your position find extremely helpful--patients let us know so often this has helped them in cases like yours: Hard Choices for Loving People booklet