DNI/DNR
Monday, July 30th 2007
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I rolled through my first month on the wards. I’ll wait for the applause to die down.
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I’ll echo virtually every medical student who has come before me in saying that it is gloriously better than the hours upon hours in the classroom that constitute the first two years of school. There is something, right off the bat, that has disturbed me and I get a feeling talking to physicians that what I’ve seen in my first month is not somehow isolated to my first facility or medicine team. What I’m a little peeved about is the hard sell of the DNI/DNR choice.
A made up situation: A patient with lung mets who develops recurrent effusions and keeps bouncing back for basically symptomatic thoracentesis. His/her prognosis is terribly poor and indeed if it was me I’d would think the best place for me would be hospice and I’d probably want to be DNI/DNR. But it isn’t me. If the patient is informed, as best as possible, and wants to be full code, doesn’t want hospice…why is that such a problem.
I understand that as health care professionals they’ve seen the consequences of full interventions on these patients. They’ve seen the futility and the actual prolonged suffering of such and they understand it in a way that just talking to the patient probably cannot relate. But shouldn’t it work that you try your best to convey your opinion and the consequences of both choices and then respect the patient’s wishes?
Do you really need to be frustrated back in the team room? Do you really need to revisit the issue with them everyday? These sales pitches I hear made to some of these patients go far beyond advice, they’re approaching car salesman level.
What Is It Going To Take To Get You DNR?
There is real futility in these choices and it burns me inside that these patients sometimes choose prolonged suffering for themselves. I know these physicians think they’re doing what is best for the patient but paternalism dropped out of vogue a while ago.
I’m also disturbed by the contention that futile full codes or hospice refusal wastes health care resources. He should be in hospice, then we’d have another bed. This health care system is the least efficient in the western world. I don’t think these patients represent a real comparable drain on the system.
As a resident in ENT, I absolutely agree with your concerns about the DNR hard sell by many of our colleagues. I think most of these hard sells boil down to two things. Fatigue and frustration! Ethics rarely enters the equation.
The number of patients you have to round on every morning depends on how fast you can dispo. You can send them home, nursing home, hospice or the morgue. Since nursing homes, especially ones that are acceptable to families are at a premium. the path of least resistance is usually hospice. If they are going to stay in the hospital, DNR/DNI make it much less work for the on-call team by cutting down on the number of codes.
If work load was the only factor, quite a few physicians would just suck it up, but they just don’t see the point. Its tough to maintain your motivation running to the third code of the night on the same patient. Particularly when you had to call CT surgery to put a chest tube in after you broke her ribs last time. When you don’t see the patient improving, no family comes to visit, and the patient is unable to communicate, all you have is negative feedback on your abilities as a physician. You just want that situation to end…
I agree that the “system” is messed up and resources are being wasted left and right, but the resource being “wasted” by that full-code, terminal patient is not the bed. It is you!
An excellent question and a thoughtful post. Here’s my two cents:
As a respiratory therapist I’ve been deeply involved in the type of situation you’re describing. I think that the reason that people get so frustrated and try so hard for the DNR/DNI option is that we’ve all seen what happens to people. It seems as if patients do not understand what they want us to do: I often find myself very frustrated when patients demand full-code treatment despite being in a futile situation. I honestly don’t think that they understand what they are asking for: chest compressions, large-bore tubes in various orifices, medical comas, painful procedures…it’s far from benign, and often, it feels as though what we are doing is simply keeping meat fresh instead of saving lives. It’s traumatic for the families and unpleasant for the medical teams, and I think that knowing that we are doing painful and unnecessary things to people can create enormous amounts of frustration. Hence, the hard-sell for DNR/DNI and the backroom ranting when patients don’t get it.
Two thoughts came to mind: (1) How specific are the doctors in describing exactly what “do everything” means? Is there a mid range where you can get across exactly what patients are letting themselves in for without being overly dramatic and frightening the patients? I’ve heard some good descriptions by docs and have often elaborated if the patient asks questions after the doctor has left.
(2) The patient should understand that they may be in no position to change their mind if they are deteriorating, ie unconscious.
But you’re right. It’s very frustrating. In the ER, we always hear “The patient is a no code but they can’t find the papers.” Which means a full on code until they do. Very frustrating.
god gave us life ! we should fight for it !
who are we to be able to discriminate the status of a patient because of the3 severity of the disease, who said the importance of life is to be able to work etc
god can see different things, different perspective
i didn’t understand yet god’s purpose but when i will find out i may email you back
I totally agree. I’m an MSII and I had to have daily discussions with doctors right before my first yr of med school when my mom was dying of breast cancer about DNR/DNI. They harrased us so much during that last week of her life that I knew there was more to it than just her potential (maybe because they didn’t prescribe stool sofeners with her opiates and she was now bleeding from her lower GI…) and I would even say probable suffering if she went through a code. We just thought the whole thing was ridiculous because it was clear to us that she was dying regardless of her code status. That little piece of paper was meaningless The doctors all thought we were “delusional” because we wouldn’t sign DNR/DNI. It also didn’t make much since because all the while they were pushing DNR/DNI they kept asking our permission for palliative radiation for her brain met. It was her last freasking week of life. Even know on the wardsi hear DNR/DNI used improperly and too casually in speach. For example we don’t entertain or even inform patients of say an invasive or radical procedure if they are DNR/DNI which isn’t unreasonable given that it is typically an person in poor health but this is not what DNR/DNI was designed for; patients should always know their options. I have also yet to hear DNR/DNI presented neutrally.
excuse my mispellings, post call..
Jan, I am sorry for the loss of your mother. I too believe that God has given a life that is precious. But I have also seen those cases when we are physically keeping a heart beating and the lungs are inflating. But that doesn’t mean that the pt is alive. As an ICU RN I am one of those that actually gets to perform the compressions. I get to feel the ribs breaking under the pressure of my weight. I get to hear the pt groaning from the defibrilator shocks.
There are times that ACLS is appropriate. But at best it is a brutal scene. There are times that ACLS is nothing more than torturing a pt. Sometimes it would benefit the medical students to actually get in there and get some HANDS ON experience. I think it would change some attitudes.
Again, I am sorry about your loss, and I am very sorry that you did not have a physician that would sit down with you and your family and lay out for the the purpose of the pallative treatment and the DNR designation. I hope that one day you will be a physician that will be more in touch with the patient’s and patient’s families needs than that.
As an ICU nurse, I often feel doctors are far too hesitant to offer DNR options. I agree - patients should be given all information and then allowed to make choices, but that often does not happen. Too often doctors and other members of the healthcare team enable denial. Even when patients are begging to be allowed to die, doctors and family members ignor them because they are considered to be too ill to make decisions for themselves. When you get out of medical school you may find it is not as easy as you think to inform patients and families about the reality of their illnesses. I challenge you to continue to hold yourself to the standard you espouse, even when you find out how hard it really is.
As a patient, I am wholly into better communication with the providers. I was addicted to tobacco at age 18 when cigarettes were 6 cents a package in the navy (no taxes). Continued heavy smoking until a quiet heart attack at age 79.
Heart stoppage on the table when undergoing stenting. resulting in 4-way bypass. Ding fine after almost 4 years. COMPLAINT: Why did not Kaiser (the medical profession) wean me from tobacco before the surgery was neccessary?
“Doing” fine (spelling). Point of this blog is that the medical profession DOES have a resposability to ease a patient’s life even to the extent of refusing to continue care. Perhaps a surcharge for their services for the stupid and headstrong patients like myself who continue a self destructive behavior.