The use of written, formalized DNR orders arose through the efforts of a committee composed of the hospital’s lawyers, ethicists, and physicians. Now the true plan for a specific patient can be spelled out in the chart without fear of legal or ethical retribution. The actual order must be written by the patient’s attending physician and must be reordered every week. Once a DNR order has been written, it leads to conflicts of another sort: Now that we’ve stated that the patient is expected to die, what should and what should not be done for that patient?
Here’s an example that’ll help explain this conflict: A patient who is DNR develops a fever. Normally, hospitalized patients who develop fever are managed very aggressively; a “sepsis workup” consisting of blood and urine and sometimes spinal fluid cultures is done, and antibiotics are immediately begun. Failing to treat a patient with fever may lead to overwhelming infection and ultimately to death. But what should be done if the patient is DNR? Should antibiotics be started on such a patient, or should infection and its consequences be “encouraged”? If antibiotics are going to be withheld, should cultures be obtained? These questions must be considered in every case. Often, under the reasoning that to treat an infection would be to prolong life artificially, antibiotics will not be given and cultures will not be obtained.
But using this reasoning, one could argue that feeding the patient would also lead to artificial prolongation of life. Therefore, should DNR patients receive the nutrition they require for life to continue, or should they be allowed to starve to death? Most physicians would agree that the withholding of nutrition should not occur. Implicit in DNR is that the patient should not be allowed to suffer. Starvation is a painful and drawn-out way to die. Therefore, most intensivists would make sure all patients were receiving an appropriate number of calories to sustain life.
These are only some of the issues Andy and Mark agonized over during their month in the ICU. And they are not alone. The conflicts that arise for young physicians at the edge between life and death are universal. And they lead to a great deal of mental and emotional stress and anxiety.
Andy
MARCH 1986
Tuesday, March 11, 1986
For the past two weeks I’ve been in the OPD at Mount Scopus and West Bronx. It really hasn’t been too bad. I’ve come to realize that I’ve had to start acting more like a resident; I have to depend more on my own impressions and make my own decisions. The past few weeks have been the first time I haven’t felt that the residents and the attendings were giving me good answers or helping me solve problems very well. So it’s been a kind of stressful learning experience, but I think I’ve been doing okay at it so far. I guess this is how you learn to become a resident.
The other night in the Mount Scopus ER was memorable. It was my last official night in the Mount Scopus ER. I was supposed to have another whole month of OPD on the west campus, but I switched to be at Jonas Bronck. Working in the Jonas Bronck ER is a better learning experience. So it was my last on call; I can’t say I’m not happy to get it over with.
It was also one of the worst nights I can remember. There was a tremendous volume of patients; they kept just coming in. It was nuts! At one point we were fifteen charts behind, which is a lot for that place, but we couldn’t make any headway because we had about a half dozen acutely ill children. And the place has only four rooms; we were spilling over into the adult ER. Let’s see: We had two head traumas in various states of coma; we had a diabetic with sickle-cell disease who was in the middle of a painful crisis and in DKA [diabetic ketoacidosis, the buildup of acid in the blood of diabetics caused by high sugar in the blood and inability of the cells of the body to use the sugar for its normal processes]; we had a little baby sickler with fever; we had a couple of vaginal bleeders and a drug overdose. All of these were occurring pretty much simultaneously. And it was just me and a senior resident who was not the greatest doctor you ever saw. We couldn’t get help from anybody. The attending was over in the West Bronx emergency room. Every time we’d call with a problem, he’d say, “Well, it doesn’t sound too bad. Call the senior in the house [the resident in charge of the inpatient service at night] if you’re worried.” He wasn’t even concerned! What a shithead!
I never ran as hard as I did that night. Finally at one point the nurse, who was fabulous, said to us, “Please call for some help!” So we did. And then slowly but surely we got some of the docs who were on call on the floors down there, and we cleared the place out. But it was still crazy the rest of the night. Right before we were going to leave, this fourteen-year-old girl who’s an asthmatic and has been intubated twelve times came in tight as a drum. [She was not getting air into the lungs. Asthma is caused by narrowing of the air tubes. When these air tubes are slightly narrowed, wheezing will be heard in the chest; when they become very narrow, as they were in this patient, no breath sounds are heard and the patient is considered “tight.”] We had to intubate her in the ER. I didn’t get out of there until 3:00 A.M., which is late for Mount Scopus.