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[交流] 【Share】Do you really want that DNR?

the article is from Alex Folkl, Medical Student, thank u

"Do Not Resuscitate." After nearly a year in the hospital, I've seen those words in more charts than I can count. We assume they tell a pretty clear story: The patient, or their proxy, having understood the process and consequences of CPR, has decided that should things take a turn for the worse while in hospital, they prefer that we let well enough alone, and allow them to die in peace.

That's what we assume, but I don't think it's as simple as that, and after considerable reflection I have to say that I'm rather disturbed by the whole process of deciding DNR status. Consider all that's implicit in the DNR order:

First, that the patient or their proxy understands what CPR entails. Do they? Every time I've heard someone turn down CPR -- every time -- they do so with some variation of "I don't want to be hooked up to a machine." And we go along with it. But "I don't want to be hooked up to a machine" is masking a deeper fear: That they will be hooked up to a machine FOREVER. This reflects a fundamental misunderstanding of what CPR involves. Yes, you might wind up with a tube down your throat, hooked to a machine. Yes, it might last a while. But you might not need that machine, and it might not last for very long at all. By not fully explaining the process of CPR -- what's always done, what might be done, and what sort of consequences the patient can expect -- I think we are doing a major disservice to people who might choose differently if they understood the process a little better. It frightens me to think that somebody should die because they misunderstood what CPR's all about.

The second piece that is implicit in a DNR status, if the patient in question is incapacitated, is that their proxy knows their best wishes. That's most certainly not always the case. As several reports have pointed out (for example, in the Archives of Internal Medicine and the Journal of Palliative Medicine), surrogate decision makers get end-of-life wishes wrong a significant proportion of the time. Practically, I think this means that we ought to spend a good amount of time talking to the proxy decision maker -- figuring out just how well they understand their loved one's wishes -- and perhaps corroborating their decision with collateral information from other interested parties, if possible (whether or not only one official proxy exists). It also means that all patients should be encouraged to put in writing, in no uncertain terms, what their end-of-life wishes entail.

The final piece implicit in a DNR status is that the person choosing DNR made their choice freely. While I would never suggest that I've seen medical staff bully someone into DNR status, I do think that the words we choose to describe the process of CPR can have unintended consequences. Imagine how frightening it must sound when CPR is described as "hooking you up to machines and putting a tube down your throat," and is left at that. People are understandably frightened by that kind of phrasing, and by not explaining the process in more detail, you may unintentionally give someone the impression that CPR is a terrible thing to be avoided at all costs, even if death is the only alternative. If they've got that impression of the process, have they made a free choice? I don't think they have.

the things I've outlined above are things I hope to keep in mind when I'm finally in the position of counselling someone considering their own DNR order.

what do u think?

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