Medical professionals and DNR

[nancylebov]

Here's an article which makes strong claims that end of life care is so painful and ineffective that the vast majority of medical professionals refuse it in favor of dying quietly at home or at a hospice.

I've seen the article cited in a couple of places and seen questions about whether the claim is true-- there's just anecdotes in the article.

So, any medical professionals care to say what your decisions are on the subject? What do you know about other medical professionals and their choices? What country are you living in?

I'm interested in comments from people who aren't medical professionals, too, just let me know whether you are or not.

I think I only have a modest number of medical professionals who are likely to comment, so if you pick up this question on your blog, please let me know.

Comments

[firecat]

I'm not a medical professional but my dad is and he has "no chemotherapy" in his health care directive. I asked him about it and he said that if he were well enough to make the decision himself, he might opt for it depending on what kind it is, but in the case of someone else making the decision for him because he can't, he didn't want to risk the suffering it might impose. That makes sense to me.

[adrian_turtle]

I am too tired to sort out the circular definitions rigorously. I will just point out that the article was about doctors avoiding "futile care" at end of life. EVERYBODY wants to avoid futile care, at end of life, or at any time. ("This chemotherapy won't cure your cancer, or significantly improve the length or quality of your life. Do you want it?") The problem is diagnosis...most people don't know what treatment would be effective and what will be futile. We have to guess, and sometimes we guess wrong.

[nancylebov]

Fair points. I think the important question is whether the guesses are apt to be wrong so often in one direction that it's important for patients and their families to push back in the other direction.

[siderea]

I somewhat disagree. I think the article points out, but perhaps doesn't adequately center the problem: we may not want futile care for ourselves, but confronting the loss of a loved one, we might chose it for them, prioritizing our own feelings of not wanting to lose them over their misery. The article frames a dichotomy between doctors and non-doctors, but it's just as much between what doctors want for themselves and what some people (patients' families, or even doctors themselves) want for others (the patients). So really, it can be read about the differences in choices we make for ourselves and the choices we make for others.

And unfortunately, that's a very hard problem, and one we can assume will persist. We know from all history that when you put one person in power over another, if there are no checks or balances to prevent it, the person in power will tend to use their power in preference of their own desires, and the expense of those they have power over. We in our culture don't have a lot of checks on the exercise of end-of-life decision making power over someone who can't make that decision for themselves. It should come as no surprise that litigation fearing doctors and distraught family members confronting loss of a loved one will choose to impose futile treatments on patients.

[caper_est]

My father came down with a pernicious cancer and accepted major therapy while there was hope - this did not work out at all well - but once its failure was clear, he went back to his old baseline of no heroic measures. We did have to use his DNR instructions to fend off the paramedics at the bitter end, though I'm pretty sure he was well gone by the time they arrived. He wasn't a doctor but knew a lot of them, and had worked for most of his life as a biomedical technician: he kept up with developments to a very high layman's level, and knew more than most about the way health services worked in practice. His idea of the proper way to die, if it could have been managed without causing a lot of trouble for other people, was what he was wont to describe as 'a big bottle of whiskey up a high mountain' when life's downward slope looked too near and steep. My metaphor is more like a last toast taken in hemlock among a small circle of friends, but... yeah. I feel pretty much the same way. Strongly so.

All I can say further without compromising other people's privacy, is my family has something of a tradition of aspiring to go out quick and clean when we have to go, and that Dad's decisions in this regard aren't exactly an outlier amongst the people I know best.

That was a very interesting link, and I too would very much like to know whether anything more than anecdata can be brought to support it. (That might be impossible, though, specifically because many of the professionals involved will not be wanting to give ammunition to busybodies, or even evidence to potential informers.)

[malkingrey.livejournal.com]

I'm not a medical professional, but Himself is an EMT and knows a lot of them, and most of them are strongly against heroic measures when it comes to end-of-life care. (As one of them said, "I'm thinking of having DNR tattooed on my chest.")

[lysystratae.livejournal.com]

I've threatened to get that same tattoo

[avram]

Now I'm thinking about a popular music band called DNR, inspiring its fans to tattoo its logo on their chests.

[inquisitiveravn.livejournal.com]

My mom, who is an MD, has talked about getting "No Code" tattooed on her chest.

[thette.livejournal.com]

0 HLR would be my choice of a tattoo, when the life quality goes down enough.

[ritaxis.livejournal.com]

I am not a medical professional: however I've been pretty closely involved with these decisions a couple of times (and, of course I do not hesitate to remind the world that my kid worked as an EMT and is a year and a half away from being Doktor!).

My feeling is that it is not as simple as "DNR" or not.

My mother always wanted me to promise I would never allow any resuscitation efforts for her. Then when she was actually dying she made it clear she wasn't sure any more: I think that was because there was a small chance that she could have a reasonable remission and get to finish reconciling with my brother. When it became clear that she wasn't going to get that we "weaned" her from the ventilator, and she died in front of me. They did resuscitate her once during that week of uncertainty.

My father was basically dead, but my stepmother kept him on life support for three days so that his close friends from around the world could get there to say goodbye to him. My part of the family didn't object because it was pretty clear that my father wasn't actually experiencing anything by that point, and my stepmother was going through a lot of heavy, heavy things at the time, including her own near-fatal stroke and the recent death of almost all her female relatives from breast cancer.

My husband died too fast to even think about it.

I've talked to my kids and I trust them to do the best thing they can think of doing at the time, which is all that you can ask.

[sodyera.livejournal.com]

Why does Amerika want you to die for their country, but not for your own reasons? Maybe it's becuase the medical lobby isn't through picking you to actual death with added medical fees. Just another test, we'll need just another test...

One should be able to determine certain things in your own life: the length of your own hair, the way you want to live, the implicit right to wear your favourite colour wherever and whenever you want, and how, or maybe even when you want to die.

Christians got it into their heads somewhere that they could push everybody around, and this led to the Republican Party becoming the American Fascist Party in disguise. All a Fascist wants to do is control things from behind, like dark puppeteers and Hindmosts. The Republicans just want women to get back in their place and vacuum the house instead of trying to run the House, or the Senate. The right to die has been accepted in many civilised countries, so it's about time this country became civlised, too.

[nancylebov.livejournal.com]

I don't think this is just about Christians, though it's possible that the fear of hell gets transferred into the fear of making mistakes.

I think part of the problem is an American trait, not related to religion or political orientation. It's the desire to do something heroic and get a low-probability victory.

This isn't entirely a bad thing-- sometimes an extraordinary effort does work-- but it can lead to ignoring sensible maintenance and kindness.

And, as you say, in this case, it leads to wanting to be in charge, not to mention that there's more money in taking drastic measures whether or not they make sense.

[sodyera.livejournal.com]

This is why I referred to the Republicans and the Christians. With them It's always money over people. People ought to have rights, esp. over their own bodies and choices.

Don't make me do Hellen Reddy.

[nancylebov.livejournal.com]

I'd like to see a timeline for the problem-- I'm pretty sure it was in place long before the current Republican dominance. And note that at least some of the R's would rather not spend tax money on it, even though they'd also rather not spend money on more reasonable things, too.

The desire to take charge of people for their own "good" isn't limited to one party.

[sodyera.livejournal.com]

Orwell.

[lizw.livejournal.com]

I am not a medical professional, but I have thought about this a lot after sitting with three relatives and one friend while they were close to dying and, more recently, visiting my father after his stroke and Parkinson's diagnosis. I have decided that death and dying are not the enemy. I would definitely prefer to die at home or in a hospice if it is practicable at the time, and I would not want to be resuscitated, fed artificially etc, if I had the degree of disability my father now has (he cannot walk, tend to his own basic needs, read anything more complex than the sports pages, or follow anything he sees on TV).

[olifhar.livejournal.com]

Good question. I'll ask around with my connections and see what anecdotes turn up.