Jack Freer, M.D.

Offering Inappropriate Treatments

David Weissman's post, "CPR Musings" http://growthhouse.typepad.com/david_weissman/
makes an important point about physician/professional responsibility in regard to CPR decision making. He notes that CPR is, fundamentally, a medical procedure. As such, it should be discussed by a "health professional prepared to make a recommendation on the use of CPR as a medical procedure, based on medical knowledge and experience."

CPR is a special situation because many states have a legal presumption in favor or CPR, should a cardiac arrest occur. CPR often must be explicitly refused via a do-not-resuscitate (DNR) order. When that is the case, and CPR is being mentioned only because of that legal requirement, I believe we have the duty to make that fact clear. If we, as health care professionals, believe there is no medical justification for this procedure, then we would not even be talking about it were it not for the law. This fact should be made clear to patients and families when we ask their permission to forgo CPR.

This brings us to a wide range of other medical options. Dying patients exhibit deterioration of a broad spectrum of physiologic functions. A patient dying of metastatic colon cancer might demonstrate evidence of renal impairment, myocardial dysfunction or respiratory failure. But it is important to remember, these are not unrelated conditions that can be separated from the patient's cancer. They are simply manifestations of the dying process. Most importantly, we do not benefit the patient in any way by providing hemodialysis, inotropes, or intubation/ventilation.

And yet, I still see these modalities being discussed in this setting. Because the physician often recognizes that they are inappropriate in the dying patient, he or she may offer them, and in the next breath, recommend against their use. This is terribly confusing to patients and families. Why would we even mention a treatment if we thought it was inappropriate? Other than CPR, (for the reasons cited above) we should probably not even mention most of the treatments we think are totally inappropriate in the dying patient. Offering a treatment validates it in the mind of patients and families (no matter how much we then discourage its use).

Finally, the language describing the decision often reflects the ambiguity we promote. More than once, I have seen housestaff document a decision to forgo a medical treatment as "refusing" the treatment, even when the resident in question felt the treatment was inappropriate. The harm done by offering inappropriate interventions, despite an explicit invitation to "refuse" the treatment goes beyond confusing patients and families. Many well intentioned or compliant individuals will consent (or even request) such therapies out of guilt or a belief that this is the way to "do everything" for a loved one. Medical decision-making is confusing enough for laypeople without having to sort out mixed messages.

Dyspnea, Suffering and DNI

Doctors and hospital workers are fond of abreviations and acronyms. So, soon after the advent of cardiopulmonary resuscitation (CPR), a decision to NOT offer this treatment was labelled "DNR." This is a handy tool for a number of reasons. Patients for whom CPR is appropriate are all very similar: pulseless, not breathing, unconscious and usually just about dead. For CPR to have any chance of success, it must be started immediately on an unconsicous patient. Therefore, the only way to avoid CPR is to refuse it in advance--to label yourself "DNR."

Apparently, medical people who liked the DNR concept and acronym, but realized it could only be narrowly applied to cardio-respiratory arrest, created another: "DNI." As far as I can tell, it is an instruction not to intubate in non-arrest situations, although I have heard a number of people try to apply it to the CPR protocol ("do everything else but intubate"). Aside from the confusion over meaning, there are bigger problems with DNI decisions. Unlike patients requiring CPR, patient requiring intubation are highly variable: ranging from someone almost dead with agonal breathing to an asthmatic with bronchospasm. The onset of respiratory failure is slower than cardiac arrest. Decisions can be made to "undo" the intubation (withdraw the ventilator), but not with CPR, which is over in a matter of minutes. Finally, the most important difference between cardiac arrest and respiratory failure is that patients in the latter group are often awake and frighteningly aware of their situation.

This is the most terrifying result of a DNI order--a wide awake patient, struggling to breathe, and the only instructions given to the nurse are what NOT to do. Little wonder many of these patients "change their minds" at the last minute and request intubation.  Intubation and ventilation are absolutely inappropriate for many patient based upon their illnesses, as well as their attitudes, values and wishes.  But their care can not be summarized in 3 letters. In talking to patients and families, we need to lay out all that we WILL be providing for them to relieve suffering and further their goals of care. Then, only as an addendum, talk about what we WON'T be providing. Likewise, doctors' orders need to detail what we will be doing FOR the patients, and only then, mention what will be withheld.