Sunday, July 25, 2010

Do Not Resuscitate vs Do Not Treat

I have been staring at this shade of grey quite a bit lately. When a patient's care shifts from 'do everything possible to keep them alive' to 'do not resuscitate' things are pretty black and white. Or so it seems. But where is the line between 'do not resuscitate' and 'discontinue treatment'?

I know that I am not wading into anything new here when it comes to the ocean of medical ethics, but I've had two cases in the past two weeks that have caused me to look at my own practice as a nurse, and the decisions I will be faced with as a physician. And I can't help but wonder if my smugness and confidence will disappear when I am the one who needs to make the call. Or will it be easier because there will be a greater distance between me and direct patient care?

Look, I know it is easy to judge orders as a nurse. We are wrapped in a protective covering of arms-length responsibility when it comes to patient care decisions. Now before people start hopping up and down I am not saying that nurses don't hold a great deal of responsibility, they do. It is just for a different aspect of the care. I have to check myself when I feel the inevitable eye-roll that comes with certain orders, or my frustrations with care plans that I don't agree with. But he bottom line is that the physician who guides the care plan is the one who is taking the risks. This I need to remind myself of, from time to time.

Yesterday I took care of someone who went from fidgeting with his bedclothes and asking to go home, to someone who was becoming less responsive and confused, to someone who was dead. And somewhere along that trajectory we all had to accept that we were not going to save him. I don't like the fact that at the beginning of my shift I was explaining to his sister that we were just doing some tests and rehydrating him, to at the end of my shift saying that we'd do everything we could to keep him comfortable.

I didn't like looking down at his purple, blue, and red arm where he'd been poked so many times already that day for blood work knowing that still more blood was going to be drawn from that site before the end of the night.

I didn't like that I didn't have time to give him a proper bath, put lotion on his feet.

I didn't like the fact that before his shit encrusted blue jeans hit the floor his children had already cleaned out the pockets for cash.

And I didn't like disagreeing with the doctors orders. Keep on the monitor. Repeat blood work. Push fluids. And yet I remind myself that it is not my medical license on the line, he was just doing his job to ensure that no one could fault his management, he reminded me that a "DNR was not an order not to treat". I get it, and to be honest, I went down that road last week already in a similar situation and I didn't feel like arguing anymore. He's actually a good physician who really takes the time to discuss the issues with family members, and he is not delusional when it comes to recognizing the point when medical science has gone the distance but simply petered out.

It's just that he gets to leave. And we are there at the bedside. Seeing the family members mesmerized by the lights of the monitor. We are the ones who have to look away from the blood pressure readings that are 59/30...53/31...50/28. We are the ones hanging the next bag of fluid that is certainly not going to drain out of the catheter. We are the ones putting the O2 sat machine on over and over again when the patient keeps pulling it off. We are the ones turning him back and forth to keep the unmoving blood from causing sores, listening to him moan in pain with any movement.

I envied the doctor last night when he finished his orders and walked out the automatic doors. I looked from the door, back to the monitor, and to the patient's sisters crying at the bedside. It was one thing to know that if he stopped breathing or his heart stopped we were not meant to intervene...but right up until that point were we improving his quality of life or just going through the medical motions?

I looked at the automatic doors again. They had closed.

The physician had done his duties and I had to keep doing mine.


ertwro said...

Once I did watched a person die. He was my grandfather. At 82 he coped for almost two years with a lung cancer that spread to his legs. He passed through pain, a kind that I can’t understand.

On that day we were called in the morning. My dad, my brother and myself stayed by his side. 4 hours he agonized, unable to breathe, all we could offer him was water since he was really thirsty.

I felt it was important to be there, but all we could do was look in shame and feel frustrated. He was scared.

He felt more and more suffocated; in one strong episode he tried to grab us for help. Doctor warned us, it was nothing they could do. Any further treatment would just lengthen his suffering.

This really pisses me off. Could he be resuscitated, what quality life improvement would he see? As a doctor I would like to prolong people’s lives, but what if I can’t IMPROVE their lives?

Whatever I choose as a doctor I will need to solve that first. If I get to do so: say I put a non-kosher valve inside your heart improving your life in consonance with the way you have chosen to live… sue my ass off if your pride tell you to do so. Gladly I will defend myself and if am fit I’ll survive it.

OMDG said...

ertwro -- There is palliation for breathlessness: morphine. I hope your grandfather got some.

ABB -- They have various levels of DNR in the US. DNR-A means no CPR, no mechanical ventilation, no pressors, DNR-C means palliation only. DNR-B is somewhere in between. Interestingly, all three levels DO involve active care, it's just the goals are different.

Watching someone die is really difficult. I think a lot of time, when people get upset that doctors are "torturing" patients with excessive treatments they forget that it's the patient who decides. Not to say that excessive treatment doesn't sometimes happen, or that doctors frequently aren't sufficiently open with their prognosis leading to poorly informed decisions. I guess what I'm saying is that the most important thing is to respect the patient's wishes. Some people really do want to die fighting, and that should be ok, even if it's hard for us to watch. (PS -- I'm not disagreeing with you.)

Hope you're doing ok! You're right, it's really hard to be the nurse in these situations. You're the one who has to stay with the patient as he dies. The doctor gets to leave the room to tend to other patients -- or go home. You have to sit there watching the patient suffocate. It can't be easy.

Albinoblackbear said...

Ertwro--I believe the most painful way to watch someone die is the way you witnessed your grandfathers passing. I am sure that experience will shape the way you approach end of life care when you are a physician. We can only hope for objectivity when situations at work strike a chord deep within us.

OMDG--Even though morphine is the go-to drug for breathlessness I don't believe it always palliates. My grandfather suffered such severe nightmares and disturbing hallucinations from it at the end that I think the drug only made his death that much more frightening for him.

Our desire to do something is hard to shake though, especially since it is so ingrained from day one in the health care field.

I *completely* agree that above all the patients wishes should be honored. If they want a tube inserted in every orifice, artificial ventilation, pressors, etc. then I say it is their choice. If they want to refuse all treatment and walk out the door of the hospital to die in their own bed (and every permutation in between) then I hope that I can facilitate that as a RN or an MD. And you're right, that is how it ought to be, even if it is hard for us to watch. After all, it isn't about *us*!

The hard part (and the nagging grey area for me) is that most of the time when we are wrestling with these issues no one knows what the patients wishes are, and it is too late to extrapolate them. So we get the family members disagreeing, the hospital staff frustrated, and the patient care ends up being some agreement/middle ground between all camps. And no one is sure what is truly right.

Thank you for your thoughts on it, you know these things are unsettling no matter who you are on team. I am doing fine, it's just been a few more rounds of "face your own mortality and the mortality of those you love" in the past couple of weeks than I am used to in the last while. I just find it good to write about it as it makes me process the thoughts rolling around in my head in a more organized (well maybe not more way.

P.S It would be ok even if you were disagreeing with me...I'd at least read your comment before deleting it! =P

Sharp Incisions said...

I definitely relate to the sort of conflict you must have felt in that situation, and why you felt the need to write about it: I reacted in a similar way when I was in similar circumstances a few weeks ago.

For what it's worth, though I left the hospital and wasn't able to follow through with this patient's care, I didn't leave this experience at the doorway (I'm a med student). That doesn't make the physical and literal aspect of caring for this patient any less of a burden* on you and your fellow nurses, but perhaps someone like me was thinking of you and appreciating the work that you do. I've linked my post below in case you're interested.

*I don't mean to sound callous by calling this a 'burden' - we will all die someday, and having to witness that, particularly on a regular basis, is a difficult thing to do.