Do Not Resuscitate

The doctor knew why his patient was still in the hospital. The diagnosis on admission was bilateral pneumonia with deep infiltrates. His 55-year-old patient, with a history of lung cancer diagnosed 9 years ago and progressive myasthenia gravis, was now septic. She had gone into respiratory distress and was on a ventilator. He also thought he knew what the family needed and wanted to hear after hospital week three. He said as much after meeting with Jane's two daughters. Although the prognosis was guarded, he told the family that he was aggressively treating the sepsis and that everything that could be done was being done. They asked about weaning her from the respirator. She was not strong enough to consider weaning at this time. “And when she gets stronger?” they asked. He knew the infections would have to resolve. “Let's wait and see,” he answered.

The daughters had a different idea about why their mother was still in the hospital and what they needed to know. She was there to get better. Even with her significant medical history, she was relatively young and very much alive in this world before she was admitted: shopping, cooking, and taking that daily walk on the avenue. There had been other hospitalizations where she was very sick, and she did get better. They knew this time might be harder but she was a fighter and they needed to try if there was a chance. They and their mother expected nothing less. The doctor told them what was wrong and what he was doing to make things right and that seemed right to them. Treat the infection, mother gets better and comes off the respirator, mother goes home.

Jane will not go home. The doctor knows that with a high degree of certainty At best, the patient will need to be trached, peged, and transferred to a nursing home for slow weaning. One more likely outcome if she becomes stable: she cannot be weaned and will spend the rest of her life in a skilled nursing facility, bed bound and completely dependent for all ADLs. The most probable outcome, his patient won't be stable for discharge and will eventually die in the hospital.

A colleague asks the doctor if he discussed this predictable outcome with the daughters. “No. It was enough to lay out the acute plan of care for this very sick patient. The family is on board.” “A DNR?” he asked. “No DNR. I didn't want to talk about that now. We are aggressively treating the patient.”

How do we consider informed consent and reasoned decisions about a plan of care? When is it enough to say there is something to treat without a word about what we think the outcome will be? And how can a patient, or the family when the patient cannot direct her own care, make a decision without measuring the outcome against what they know gives meaning to the patient's life?

The doctor returned to Jane's room. It was easier for him to talk about the patient's current medical condition and treatment, then what he knows he needs to tell them now. He begins haltingly with the weaning when Jane's younger daughter, who is a nurse, interrupts him; “If she gets that far. If she survives. And a nursing home is not what she would ever want. If you knew our mother, how she lived and how she fought her illnesses, spending her last days on a respirator in a bed in a nursing home would be horrible to her.”

It's done. The unthinkable had been in the family's thoughts and the doctor had spoken the unspeakable. It was easier then he imagined, even with the daughters weeping. The words were in the air. He asks, “What would your mother want if she knew what we know and could speak to us?” “This is not the way she wants her life to end,” they answer.

The doctor talks about choices. Is it time to move from acute to palliative care; moving from aggressively treating illness to aggressively maintaining comfort? And the ventilator; what should we do about that? Their mother did appoint them as her health care proxy. They have the authority to ask us to remove her from the life support.

Knowing is not enough; knowing what their mother wants and that she will probably die in the hospital. “It's too early for palliative care. She is strong. Maybe she can beat this infection and come off the respirator. Can't we see how she responds to the antibiotics?” they ask. They are not ready to give up or say goodbye. The doctor's answer is yes.

And now for the DNR. What should be done if their mother's heart stops? He explains that given her multiple medical problems, she might go into cardio pulmonary arrest and is a poor candidate for CPR. There is hesitation. He asks what they are thinking. They don't want to give up on her, and they fear the doctors will if they agree to the DNR. He offers reassurance without giving false hope. “She is a very sick woman and the chances for the recovery that she would want are poor. Still, there is always the possibility she will respond to treatment and we are doing everything at this point that can be done. The infection is the most immediate concern. There are multiple organisms that make her septic. We have done cultures to determine which antibiotics to use and our hope is that the treatment will work. We continue to treat with a DNR in place.” They ask for the DNR.

Jane became increasingly unresponsive and died 3 weeks later on the respirator. When her heart started to fail, her daughters were at her bedside. The end was peaceful as she slipped away. This might not have been the death Jane wanted. It was the death her children could live with after she was gone.