The Door to Care Can Be Shut Too Quickly
When patients—or, very often, their families, who are supposed to be representing their interests—insist on continuing care even though death seems near, their pleas can often be just wishful thinking, based purely on emotion. In a 2009 study of family members of intensive care unit (ICU) patients, 32% would choose continued treatment for their family member despite being told that there was less than a 1% chance of survival.
But in a surprising number of cases, the family is right: The right amount of "heroic" care could turn things around and provide many extra years of life. This was the case for the elderly mother of Kathleen Finlay, founder of the Center for Patient Protection, which advocates for patient rights in the United States and Canada.
In a 2013 article on the center's website, Finlay recalled doctors' premature efforts to let her mother die. In 2008, when her mother was in her 80s, she was admitted to a Canadian hospital with a serious infection. The doctor asked the family to sign a "do not resuscitate" (DNR) order, which involves withholding cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest.
The family refused to grant a DNR, citing their mother's wishes. But the doctor didn't take no for an answer, Finlay wrote. He went directly to Finlay's mother and sought her consent for a DNR. Even though she was delirious with a fever, the doctor decided that he had gotten consent from her and ordered the DNR.
The doctor had some good reasons to push for a DNR. CPR can break ribs and often doesn't work. In a 2013 study, of the 71 patients who had had CPR, 22 had at least one broken rib, and 14 had multiple breaks. And in a 2012 study, limited to people who had CPR after experiencing cardiac arrest out of the hospital, fewer than 5% survived after 1 month.
But the family also had good reasons to fear a DNR. Having a DNR in your chart can set you up for poorer care. Although DNRs are supposed to be limited to withholding CPR, they can be misinterpreted to mean withholding other interventions, according to a 2002 study. That still seems to be the case today. A study published in 2015 showed that even when DNRs were given to cardiac patients with the best prognosis, these patients experienced lower survival rates and less resource use than similar patients without DNRs.
Back to Finlay's mother: Against the doctor's expectations, she recovered and went home. A few years later, at age 89, she was again hospitalized, this time for cardiac arrest, and the physician in charge again wanted to place a DNR order. This time it was a resident who told Finlay that for patients her mother's age, the chances of surviving another cardiac arrest were almost zero, but the family refused to authorize a DNR, and this time the decision stuck. Lo and behold, Finlay's mother had another cardiac arrest, but she received CPR and recovered.
Three years later, when Finlay wrote her article, her mother was still alive. "She remains curious about the world around her, engages in conversations, and enjoys her music and her garden," the daughter wrote. "How would we feel today if we had deprived her, and ourselves, of that by acceding to the hospital's urgings?"
Medscape Business of Medicine © 2016 WebMD, LLC
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Leigh Page. 'Doctor, Don't Give Up on Me!' - Medscape - Mar 16, 2016.