I received this article by email the other day. It describes one physician’s take on the issue of DNR in relation to a physician’s own ethics. The author questions why doctors would not advice patients the same as they would act themselves when faced with the same discussion of choosing aggressive treatment over allowing natural death. I find his honesty refreshing. I find that his commentary actually revolves around a greater ethical problem, the issue of autonomy over paternalism. It is almost as if many physicians want to avoid the instinct to instruct so much that they tell patients things they would never really want to advise in the first place.
WHEN DOCTORS IGNORE ‘DO NOT RESUSCITATE’ ORDERS
by Russell Saunders
When it’s my time to go, I hope it happens without a fuss.
In the event that I suffer from a terminal illness, once the point has been passed where a return to health or meaningful quality of life is no longer a realistic possibility, when further treatment will do nothing but fill my days with more of itself, then I want that treatment to end. Though I hope such plans are a long, long way from ever being enacted, my husband and other loved ones know that I would not want “heroic” measures to prolong my life, and would choose a peaceful rather than a protracted death.
I am not alone in this. A new study in the online journal PLOS One reports that most of my fellow physicians feel the same way. The authors of the study surveyed over a thousand doctors, and just over 88 percent of them reported wanting an advance directive that would stipulate “do not resuscitate” (or DNR) status at the ends of their lives. I would have answered precisely the same way.
Those results do not surprise me in the least.
I cannot imagine going all the way through medical school, to say nothing of residency, without witnessing cases where patients received medical care that prolonged their existences but not their lives. It is a common enough occurrence that I would generalize it to essentially every graduate of medical school. We’ve all seen patients given interventions that preserved the functioning of their organs without any hope that the people themselves would have anything but misery to number out their days.
Why is this so? Why does the same study report that doctors will often override an advance directive if it conflicts with their clinical decisions that further treatment is warranted? Why would we order medical care that we do not want for ourselves?
At io9, George Dvorsky mentions the cynical possibility that physicians might do this for the sake of charging for lucrative end-of-life treatments. In the Pulitzer Prize-winning play Wit the central character is subjected to prolonged end-of-life interventions because her doctors care more about their medical studies than about her. I would love to believe that this never really happens, that members of my profession put the wishes and well being of their patients before any other considerations, but I would be a fool to be so naive. Sadly, even the mother of a close friend of mine was treated in this manner. I am sure that this happens, as loathsome as I know it to be.
However, I do not believe that most physicians opt for extensive treatments for their dying patients for this kind of reason. I suspect that for most of us, it’s due to a more complicated and less appalling set of considerations.
First of all, prolonging and supporting patients’ health and life is the entire reason for taking care of them in the first place. With the limited exception of medical providers who specialize in palliative care, we strive for our patients to recover, to leave our practices and clinics cured, or (failing that) well enough to have a baseline quality of life that justifies our being involved in their care in the first place. Letting go of this cardinal goal can be immensely difficult. If we can’t make people better, then what exactly is it that we’re accomplishing?
Further, there is always the fear of being accused of not doing all we could. The more we treat a patient, the less ambiguous our attempts to give them the best care possible. What better defense can there be against the threat of legal action than a full-court press at the very end? Though it’s a difficult factor to quantify, I suspect this kind of rationale undergirds a lot more of the aggressive end-of-life care that patients receive than many medical providers would care to acknowledge.
There seems to be little space for any kind of nuanced or challenging conversation along these lines in our society at this time. One need look back no further than 2009 and the blight on our political discourse that comprised the “death panels” discussion, in which quondam vice-presidential aspirant Sarah Palin proclaimed that the Affordable Care Act would empower faceless bureaucrats with the authority to pull the plug on grandma.
Deemed the “Lie of the Year” by PolitiFact, what the law would have done (before the specific provision was stripped) was compensate doctors for appointments where they actually talked with patients about their wishes for end-of-life care. Thanks to the former governor of Alaska, physicians who choose to sit down with people and hear what they would want if they were dying cannot get paid for doing so.
But really, this kind of conversation is hard for doctors in general. We are not nearly as good as we ought to be at talking about the reality that even the best we can offer won’t fix everything, and that everyone eventually dies of something. In modern medicine, every death is a defeat, and every illness is merely a chance to prove our worth as diagnosticians and healers.
As a pediatrician, I am generally spared this kind of conversation. Almost all of my patients are basically healthy. But even when I had a chronically ill patient who had a DNR order and was showing signs that he might be dying, I made sure to mention that more aggressive treatment was available should the mother opt to choose it, though I certainly did not push for it.
Watching a patient die without trying to stop it is not only contrary to our impulse to fix things, but it is obviously an irrevocable clinical decision. I can understand all too well how members of my profession would be terrible at making it.
And yet we must do better. We cannot routinely deliver medical treatments that we would not want for ourselves if patients have made the same decisions we would. I would want my loved ones to advocate fiercely on my behalf to have my end-of-life wishes honored, and we must improve our ability to honor similar wishes when they come from people who have entrusted their care to us. Dying patients are among the most vulnerable that we will encounter in our careers, and our duty to minimize suffering we would spare ourselves is a sacred one.