September 24, 2008

DNR does not = Do Nothing

I'm finishing up my write up tonight and my last Problem to be addressed in the Assessment/Plan is a terminal condition. I found this article on the subject from Family Physicans/Residents pondering the subject. I'm wondering if this is something I should bring up with my patient since I've avoided it in all of my previous conversations with her.

Discussions of "code status" on a family practice teaching ward: What barriers do family physicians face?

One of the things that bothered me when I was a hospital volunteer in high school was the very STRANGE pronouncement in my opinion, on the doors of some of the patient rooms: "DO NOT RESUSCITATE." Even as someone tangentially related to the healthcare field at the time, I thought it was an overtly insensitive and harsh statement. I think my reaction could be summed up as "Why are you banning people from getting healthcare?!?! Isn't that the REASON they are in the hospital?"

I'd like to emphasize that no decisions are final and “Do Not Resuscitate” does not mean “do nothing”. A term like “Allow Natural Death is equivocal in meaning, but very different in the eyes of a patient and their family. It adheres to their wishes to have “everything done” so they do not feel like they are giving up, without prolonging their suffering with unnecessary and futile medical care.

Ultimately, “Allow Natural Death” is a permissive activity, asking patients if they feel at peace and are willing to let go.
Do Not Resuscitate” is a dismissive activity and patients may feel ignored or that they would get worse care this way.

As an aside, this is a great example of connotation versus denotation. I struggled to remember these two vocabulary words for about half an hour now. Whew!

This is not the case! One thing I am learning right now by following my residents into the ICU is that many patients who are "Full Code", meaning they will be resuscitated to the fullest extent regardless of the quality of life and eventual outcomes for the patient receive TERRIBLE care as a result... getting hit with all sorts of hospital acquired illnesses from drug-resistant bacteria, thrashed with drugs that work so hard to provide blood to the heart and brain that they literally amputate limbs from within... my goodness.

What is necessary in the hard times when a patient is on their last limb before they go is an honest and heart-to-heart discussion between a knowledgable individual (the doctor) and the people who will ultimately have to make the decision for someone to die. NOT live or die. Just die. There's no other options for a lot of these folks and THAT is the concept that must be conveyed appropriately to the general public who don't know what tonic-clonic twitches are, the different categories of death ranging from asystole to brain death to cessation of all biological function and a shift to true equilibrium. I know I've made no effort of my own to define these words. That makes me a hypocrite (for now.)

Feel free to discuss this topic in the comments (and I'll chime in with my definitions later.)