Shock Me, Tube Me, Line Me: An ER Doc Reassesses DNRs
March 9th, 2010
by
Chris Fleming
|
In “Shock Me, Tube Me, Line Me,” a Narrative Matters essay in the February 2010 issue of Health Affairs, emergency physician Boris Veysman sets forth his own version of an advance directive and challenges common perceptions about care at the end of life. An excerpted version of Veysman’s essay appears in today’s Washington Post Health and Science section, and it has provoked a vigorous conversation among commenters—just as it did among Health Affairs readers.
Veysman recounts the exhilaration he feels after successfully resuscitating an elderly patient, followed by shock when the family appears and informs him that his patient is in the end stages of cancer and has standing “Do Not Resuscitate” and “Do Not Intubate” orders. “I get the story—several failed rounds of chemo; several weeks of weakness, decreased appetite, and depression; many days of feeling unwell. I hear that her meds don’t include appetite stimulants, antidepressants, or narcotics; why not?”
With the patient still in a coma, Veysman advises the family to authorize dialysis to treat her kidney failure:
I think there’s a good chance she is fixable in the short term,” I say. “She needs dialysis, but other than that we can address every other comfort issue. I think she can wake up and talk, probably even write or use a computer. I think her depression, weakness, appetite, dehydration, and malnourishment can be effectively treated. Whatever her prognosis is from the cancer, I think she can probably get at least a few good weeks, which is done best by a spice. She might want to do something with that time. To finish up. To say goodbye and good luck. I think it’s too early to die. To give her a chance, however, we must go all out and ‘do everything’ for the next several days.” I pause and add, “You can always change your mind,” addressing a family’s fear.
The family, however, with “burnout in their eyes,” opts for comfort care only, no dialysis. “Their will to fight quit weeks ago, after this patient’s minor symptoms from the chemo and cancer were left unaddressed, leaving the impression that her life wasn’t worth living. No amount of hope in my heart can rekindle what has died in theirs,” Veysman writes. The patient is removed from her ventilator and placed on a morphine drip, and she expires peacefully several hours later.
Veysman says this case illustrates that that “the concept of DNR, however ethically sound and well conceived, can be complex and contentious. This is especially so as advances in symptom and comfort therapy and medical technology providing short- and long-term support for failing organs continue to pose challenges to the use of advance directives.” Invoking individuals such as Stephen Hawking and Christopher Reeve, who have lived full lives despite disabilities, Veysman declares that he refuses to have a DNR or DNI order for himself. He concludes:
It’s so easy to let someone die, but it takes effort, determination, and stamina to help someone stay and feel alive. Only after you made every effort to let me be happy and human, ask me again if my life is worth living. Then, listen, and comply. At that point, if I wish to die, let me die. But until that happens, none of us realize what I can accomplish with another day, another week, another month. So do it all for me. Then ask someone to do it all for you.
Responses To Veysman’s Essay
Some commenters at the Post applaud Veysman. An example:
This was an excellent article. Thank you, Dr. Veysman. The response from physicians and others here is scary. The family had burned out. I know the phenomenon well first hand. That other physicians did not take basic steps to improve the patient’s quality of life because they knew that [the] condition was terminal is thoroughly reprehensible. That the family was convinced that prolonging life would inevitably cause further suffering for the patient is not surprising given the patient’s previous care. The unnamed culprit here is the attitude in the medical profession that patients in this condition are simply not worth bothering about. Veysman was not “playing God.” It was rather the other physicians and family members who decided to end the patient’s life.
But many commenters take issue with Veysman’s actions and his point of view. For instance, one commenter states:
As an emergency medicine physician in practice for over 20 years I must say, “Shame on you Dr. Veysman”. I cringe to think how you added to the suffering of this patient’s family and how poorly you understand the role of western medicine. Until you had the DNR order in hand you had to proceed with full resuscitation efforts but once the family arrived on scene your mandate as a physician and as a human being was to change gears; to respect the DNR decision that was already made, to enable the patient to die with whatever dignity could be afforded, and to demonstrate understanding and compassion to the family in their desire to honor their family member’s wishes and at a time of great sadness.
You can read all the comments on the Post’s Web site, and watch for more reactions to Veysman’s essay coming soon in the letters section of the April Health Affairs issue, to be released on Tuesday, April 6.
Veysman authored another Narrative Matters essay dealing with end-of-life issues, “Full Code,” in the Sept/Oct 2005 issue of Health Affairs. In that piece, Veysman describes the experience of treating a terminally ill patient who changes his mind from day to day regarding whether he wants to be intubated should breathing become difficult. The Post also printed an excerpted version of an earlier Health Affairs Narrative Matters essay by Jack Coulehan, “Shingles Does It,” in which a physician and medical professor who arrives in the ER with a bad case of shingles describes what it’s like to be a patient in pain during the age of aggressive medicine.
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