Saturday, February 11, 2006

End-of-Life Questions Strike Again

One of my most beloved patients is struggling with a recurrence of cancer that is giving him and his wife (and the entire care team) a run for their money. While I strive to keep him comfortable and at home, with as few horrible symptoms as possible, his current palliative chemo regimen is a major challenge. After managing to have him urgently evaluated this week for a fever and dehydration, it turned out that his white blood cell (WBC) count was so low that a virulent infection had raced through his blood and challenged his ability to survive. Before he lapsed into semi-consciousness, he and his wife signed a DNR (Do Not Resuscitate) order so that, in the case of cardiac or respiratory arrest, he would not receive the violent compressions of CPR or other heroic attempts to save him.

The evening of his admission to the hospital, the patient's wife received a late-night call from the attending oncologist who said that the patient's blood pressure was almost non-existent and they could not give him medication (vasopressors) to raise it as he was a "DNR" and raising the BP with meds would be considered a form of resuscitation(!). Needless to say, she was shocked, and the doctor agreed to administer fluids which might increase the blood volume enough to raise the pressure to a level supportive of life. Luckily, the fluids worked and he lived through the night, but the issue of what "DNR" really means was raised.

The next morning, when I learned of these calls to my patient's wife and heard that medications had not been used due to his DNR status, I was non-plussed, and immediately contacted the primary physician, who could also not believe what he was hearing. When I finally made it to the hospital, I met with two residents working under the oncologist who made the original call to the wife, and they reiterated that giving vasopressors was considered a form of resuscitation. I argued that this was not within the generally accepted definition of DNR orders, but they insisted on their position and I urged the primary physician to bring this issue to the head of oncology as soon as possible.

Decisions regarding end-of-life care are difficult enough, but when nuances like those described above are not fully communicated to the family---or agreed upon by members of the medical and nursing teams---trouble is afoot. I acknowledge that the oncology team may very well be technically correct in their assertions, but that does not preclude the fact that most individuals and families who choose a DNR order do not know exactly what they are signing for. From this experience, I suggest to anyone considering signing such an order, make sure you also have a living will or other document stating exactly what your express wishes are, including CPR, intubation, IV fluids, antibiotics, and other treatments encountered during serious and critical illness.

I will make sure that this issue is revisited ad nauseum within my workplace until we can identify the facts of the matter. For my part, I'm thrilled that my patient lived through that night, and that the conversation regarding what consituted proper care for him under the circumstances was not conducted post-humously.
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