July 26, 2010

• How to make someone DNR

  On several occasions I have written about making a patient DNR (do not resuscitate); about the difficulty, the responsibility, the power of convincing someone to just let their loved one go, to not force them past their allotted time on earth. I have written about how I have helped others deal with this all too common modern medical situation. I have written about why I think it’s a good idea that everyone have an advance directive. 

  And yet, I realized I have never written about how I actually go about it myself. You know my basic formula based off Dr Folkmans advice, but how does one go about convincing a patient or family to change from “do everything humanly possible to keep my loved one alive” to “I dont want them to suffer anymore, if anything happens let them go.”

  Well the first thing I always do is introduce myself. Nobody wants to be having life and death discussions with a stranger. So my goal from the get go is to build trust and rapport, to convince the family I am on their side, that I am using my education and experience to do what is best for everyone. Next I ask what the family understands of their loved one’s condition thus far. Oftentime people may be unaware of just how sick their loved ones are. They see someone come in with a minor infection or some mild chest pain, and not understanding the disease process, become frustrated or surprised when people appear to get worse in the hospital, a place they brought them too for healing. When the family explains how much they know, it gives me a better idea of how much further I have to take them.

  I repeat myself. Often. I use a lot of stock phrases such as “his condition is very serious” or “she hasnt been doing well” peppered liberally throughout my talk. If anything I sometimes use my authority to overestimate slightly how close a person may be to death, so the family has no choice but to confront the issue now rather than a last minute phone call in the middle of a code by a covering doctor or someone from the crash team.

  And after I have explained what is going on, after I have told them what critical interventions we have been doing to simply maintain the current level of awareness/health however dubious it may be, I start rolling out the big guns, and just like on Jeopardy I do so in the form of a question.

  “Now have you and the patient ever discussed what treatments they would like if they were in this condition?” 

  Unfortunately, in many people the answer is no. So I take two steps forward and one step back. I try first to personalize the issue for them, reminding the family that they know the patient better than I do, and ask them about their quality of life before hospitalization compared to know with whatever hospital needs they may require. I ask them if the person was standing there with them able to see themselves lying in a hospital bed, what would they want done. Would they want to continue in this way.

  This may all sound very manipulative, and I cant deny that on some levels it certainly is. But I am not just running willy-nilly through the hospital trying to off people left and right. The people I take this approach with often have been unable to confront this on their own, have been in a state of denial and even if they decide they still want everything done, futile care though it may be, even the discussion gets them started with the process of preparedness, of acceptance, of realistic expectations.

  That said, I dont leave people all open ended with a simple here are your options, full code, dnr, or cmo. That would be failing both myself and them. Most people are rarely confronted with the complexities of death on a daily basis and may not know when treatment is futile. For a doctor to tell them all this and then walk away saying what would you like is as useless as not discussing the subject at all. After the discussion noted above, I offer my recommendations. I tell them, if it were my family member, I would make them DNR, or cmo if the case warrants it.

  And then I emphasize that do not resuscitate does not mean do not treat. Just because I dont think someone should undergo the suffering of rib fractures from compression, or electrical burns from defibrillation, should not be subjected to weeks on end of mechanical assisted breathing, should not lie in a bed full of tubes pouring out of every orifice does not mean I instantly leap to withdrawing care and starting the morphine drip. I start back at square one reminding the family how serious the condition of their loved one is, and ask them to consider allowing a natural death, or a death with dignity to occur if the body simply cant take anymore rather than forcing them back into life repeatedly.

  I carefully avoid any reference to my own religious beliefs unless directly questioned. They have no place in this discussion, although respect for the families beliefs does. I repeat these conversational tidbits until the family gives me a clear reasoned response. Either they agree with my recommendations and change the order, or they tell me they still want everything done. And regardless of my own feelings, I accept that clear answer when given. If I disagree, I wait until another day and bring the issue up again. Sometimes it takes a few days for the veil to lift from someones eyes.

  After having just one of these discussions this morning, one of the fellows relayed back to me that the nurses had spoken with him and told him I had done a great job of handling the family and discussing one of the harder topics in medicine. While nice to hear that I am deemed by my peers to be performing so well, I wish I hadnt become so proficient at this talk so quickly.

  -Dr J

  • 1:26 am
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