Peanuts and Paprika

The Spice of an Average Life

DNR: Thoughts on Autonomy/Beneficence/Nonmaleficence/Justice Thu 1 Dec 11

Filed under: Uncategorized — Lara @ 11:29 pm
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Lost my first patient today. He’d been in the hospital more than a month. Shortly after I saw him during morning rounds, he just stopped breathing. Then his heart stopped beating. Then the nurse called our team to tell us he was gone. We’d barely made it down the hall.

In med school, we’ll occasionally have lectures in ethics. There are four core ethical principles in medicine.

Autonomy: The patient has the right to make decisions about their own health. If the choices are antibiotics or death, you have the right to decline the medicine. It’s your body, it’d your life, and you get to do what you want with them. That’s only fair.

Beneficence: Do what’s good for the patient. Obviously, this takes a backseat to autonomy, as in aforementioned example, with one exception. If the choices are antibiotics or death, and sepsis has made you mildly psychotic, you can’t decline the medicine. You’re getting the antibiotics one way or another, because you don’t currently have the mental capacity  to make that decision.

Nonmaleficence: The classic “do no harm.” This is probably the principle that is most violated, though not intentionally. Everything we do has risks; most medicines we hand out are poisons. This is one reason a doctor always informs you of the risks of a procedure before you consent. The other reason is because no one wants to get sued. Cynical, but true.

Justice: Everyone gets treated the same. The chairman on the board of directors gets the same treatment as the homeless man off the street. Ideally, anyway. And we do try… But someone without insurance and without money isn’t getting into an inpatient rehab facility. Wealthy people live longer; it’s statistically proven.

And so we return to my eulogy for Mr. W… It’s not even a real eulogy; I can’t use his name, and I don’t know much about his life. He was in bad shape when I first met him, and he didn’t have any family around. Heart failure, liver disease, too much fluid in his abdomen, trouble breathing. Infected ulcers all over his legs, could barely walk. Every time we thought we might be able to send him home, he’d get worse again. He became septic — with Pseudomonas. (NO ONE gets Pseudomonas sepsis.) We limited the amount he could drink, but he just got out of bed, went to the bathroom and drank out of the faucet. His abdomen filled with fluid again. Most days, he looked pretty miserable. A couple weeks ago, his blood pressure plummeted. His belly was huge; his heart was just too weak to circulate blood. Sent him to the RICU (Respiratory Intensive Care Unit) last week. While he was there over the weekend, he coded:  his heart stopped. The default action in medicine is to keep people alive as long as possible, so they brought him back. But his brain had suffered some damage from being without oxygen. He was transferred back to our service this week, unresponsive. His sister had flown in from California, and she had made him DNR level 3. This is how I saw him today, just before he died.

I’m sure Jenni already knows all this, because designating living wills was her actual job — but I’m going to explain it anyhow. DNR is “do not resuscitate.” (Not to condescend, I just want to be clear.) DNR level 1 means that if you die, we let you die. We’re not going to put you on a ventilator or do CPR; we’re just going to let you go. DNR level 2 is a weird category; it’s a “pick and choose” sort of deal. DNR level 3 means we make no attempts to keep you alive. We don’t try to fix you at all. We don’t treat your diabetes, or your clots, or your infections; we just keep you comfortable, and we send you to hospice.

Mr. W was the first DNR level 3 I’ve seen. It seems like giving up. It’s like accepting that there’s no hope. We’re just going to try to take away the unpleasant feeling that goes along with dying.

I was hoping that by the end of this entry I’d have some answers, I’d have a better idea of how I feel about it all:  about DNR, about letting patients die, about trying to fix someone and failing. I’m personally not very good at accepting death. Most times, of course, I have no choice. But what if I did… What would it take to make me choose death for someone I love, or for myself? In what situation would I finally say, let them die?

Maybe with time, I’ll get over my discomfort with death. Maybe I’ll get over the fear, and I’ll learn to love it, accept it, and to appreciate it as a natural corollary to existence, one that’s just as beautiful as life itself. … But I doubt it.


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