Sunday, November 29, 2009

When DNR Doesn't Apply

My patient coded on the OR table. It's something every anesthesiologist dreads but is as inevitable as the sunset. My patient was undergoing a procedure in a last ditch effort to prolong his life that was racked by a self-inflicted end stage chronic condition.

He had already made his intentions clear when he made himself DNR/DNI. He came to the hospital with severe anemia. The primary physician tried to convince the family to give the procedure a chance to save him. The family was ambivalent. He then told them the patient wouldn't need to be intubated. They relented. When I saw him, I knew there was no way the procedure could be performed without a protected airway. The primary team then told the family the patient will be intubated for the procedure but will be extubated when it was finished. The procedure was performed and the patient subsequently coded on the operating room table. He was defibrillated and revived. He was then transferred to the ICU intubated. Over the next week he had multiple lines placed. Pressors were eventually started to maintain his blood pressure. The patient ultimately succumbed to ARDS one week later. He died the way he had hoped to avoid, a painful, artificial death.

Doctors like to blame patient families for sticking the ICU with a ward full of 90 year old grandmas with no hope of going home but refusing to "pull the plug." But are doctors complicit in denying patients their dignity when they pass away? In reality many doctors give families false hopes, always going for that one last OR procedure, one last CT scan, one last PEG tube. It's hard enough for families to let a loved one go, but when doctors tell them that they might be able prolong life, even if it is of questionable quality, what family wouldn't want everything possible?

And what is the role of anesthesiologists? We are frequently requested to perform anesthesia for procedures of dubious merit. Is it ever right for us to say no? That would just make the surgeon your enemy far into the future and the family wouldn't believe you anyway. They trust the surgeon who has been in family meetings with them, not the anesthesiologist they just met five minutes ago. When a family member does ask me what I think about the procedure, all I can say is that the surgeon feels it is justified. My input is not really being asked for; they just want a confirmation of their concerns. I'm also not privileged to witness all the complex family interactions that may be present that led to the procedure being performed. It is a difficult position for anesthesiologists. At best we take a deep breath, cross our fingers, and prepare for the worst, which was what happened here.

No comments:

Post a Comment