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Dr. Karnik is Director, Pulmonary Care Unit, Nassau University Medical Center and Associate Professor of Clinical Medicine, State University of New York at Stony Brook.
Correspondence to: Ashok M. Karnik, MD, FCCP, Pulmonary Division, 10th Floor, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY 11554
Life has been described as being, in many ways, a river: "God makes the rivers to flow. They tire not, nor do they cease from flowing. May the river of my life flow into the sea of love that is the Lord."1 Or as being a journey: "Life is a journey from the cradle to the grave and beyond, and back to the cradle and on from life to life."2 We do our best to help our patients overcome the obstacles during this journey that are posed by various illnesses and accidents. We make them better, and on they go with their travels. But as the patient nears the end of this journey, our focus changes. The intent at that time is not to cure, but to palliate; not to be a mere academician, but to be a sensitive and compassionate physician who respects the dignity of the patient and family, and their right to refuse treatment.3 It has been said that "a good physician knows the difference between postponing death and prolonging the act of dying." A physician who has understood and assimilated this advice will be able to provide excellent care to his patients as they approach the end of life. Dr. Roger Bone, who has written poignantly about his own experience with the process of dying, in his guide entitled Reflections4 has said: "Dying can be a peaceful event or a great agony when it is inappropriately sustained by life support."
When the patient reaches the end of his journey, and life as we know ebbs out of the body, we are faced with different types of puzzling questions and painful decisions. Should you or should you not revive this patient? Who makes that decision: the patient, the family, or the physician? Besides the patient, who else has the moral and legal right to make this sensitive and irrevocable decision? Should this decision take into consideration the patient’s age and the type of underlying disease? Should cost ever be one of the considerations? What should a physician do, if, in his judgment, it would be futile to resuscitate the patient, but a do-not-resuscitate (DNR) directive was never signed or is not available in an emergency, or if the family wants "everything to be done"?
In this issue of CHEST, Kelly and colleagues (see page 957) have sought to answer one of these questions. In a questionnaire, they presented 20 clinical vignettes based on their actual cases and asked the physicians to quantify the strength of their opinions on discussing and recommending DNR orders. They found that pulmonary/critical-care medicine physicians were significantly likely to recommend DNR orders more strongly than were cardiologists, house staff, and general internists. Among the house staff, the likelihood of recommending a DNR order correlated significantly with increasing years of experience. Thus, it appears that the strength of DNR order recommendations vary with the specialty training and the experience of the physicians. Mebane and colleagues,5 in a mailed survey of 280 white and 157 black physicians, found that with regard to physicians’ preferences for future treatment for themselves, for a persistent-vegetative-state scenario black physicians were more than six times more likely than white physicians to request aggressive treatments (ie, cardiopulmonary resuscitation [CPR], mechanical ventilation, or artificial feeding for themselves [15.4% vs 2.5%, respectively; p < 0.001]). In a survey of Japanese physicians in Japan and of Japanese-American physicians in the United States, Asai and colleagues6 found that Japanese-American physicians were less likely to recommend CPR for their patients or for themselves compared to the Japanese physicians. Another factor that seems to affect end-of-life decisions is the status of the attending physician. Kollef7 found that patients who were cared for by a university-based ICU attending physician, compared with patients who had a private attending physician (either community-based or university-based), were more likely to undergo the active withdrawal of life-sustaining treatment.
The decisions pertaining to end-of-life care obviously would be made by the physician in consultation with the patient and the family. The physician, however, needs to remember that there are numerous factors that influence the patient and families’ attitudes and decisions in this regard. Some of the strongest factors seem to be the underlying disease and its prognosis, and race or ethnicity. Frankl and colleagues,8 in a survey of 200 medical inpatients, found that life support was desired in 90% of the patients if their health could be restored to its usual level, in 30% if they would be unable to care for themselves after hospital discharge, in 16% if their chance for recovery was hopeless, and in only 6% if they would remain in a vegetative state. Caralis et al,9 in a survey of 139 respondents, found that more African-Americans (37%) and Hispanics (42%) compared to non-Hispanic whites (14%) wanted their doctors to keep them alive regardless of how ill they were. Shepardson and colleagues,10 in their sample of 90,821 consecutive admissions to 30 hospitals, also found that the rate of DNR orders was lower in African Americans than in whites (9% vs 18%, respectively; p < 0.001). Wenger and colleagues,11 in an observational study of 14,008 hospitalized Medicare patients, found that DNR orders were assigned to 11.6%. After adjustment for patient and hospital characteristics, DNR orders were assigned more often to women and patients with dementia or incontinence and were assigned less often to black patients, patients with Medicare insurance, and patients in rural hospitals. Vaughn and colleagues12 also found that race plays a role in these choices. Japanese residents of an Asian nursing home were more likely to be "no code" (ie, CPR would not be initiated on cardiac arrest), while controlling for age, comorbidity, gender, and religion, whereas Chinese residents were more likely to be "full code" (ie, CPR would be initiated on cardiac arrest). Authors attributed this difference to social values and cultural differences. Tulsky et al,13 on the other hand, found no relationship between ethnicity and the presence of a DNR order, even after adjustment for covariates and separate analyses for patients who died in the hospital vs those who were discharged from the hospital alive. Hopp and Duffy,14 in their survey of 454 whites and 86 blacks found that whites were significantly more likely than blacks to discuss treatment preferences before death, to complete a living will, and to designate a durable power of attorney for health care. The treatment decisions for whites were more likely to involve withholding or limiting treatment, whereas for blacks the treatment decisions were more likely to be based on the desire to provide all care possible in order to prolong life.
If the decision not to resuscitate a terminally ill patient seems to be a logical and appropriate step, why is it not done more often? A lack of awareness of the patient’s wishes and a lack of communication between the patient and his physician seem to be the major impediments.15 16 17 18 Eliasson and colleagues19 reviewed the medical records of 88 patients in whom DNR orders were indicated but were not written. They found that the attending physicians’ explanations for not writing DNR orders in these patients included the belief that the patient was not in imminent danger of death (56%), the belief that the primary physician should discuss DNR issues (49%), and the lack of an appropriate opportunity to discuss DNR issues (43%). No physicians expressed concerns regarding the morality of DNR orders, discomfort about discussing end-of-life issues, or the threat of litigation.
There is great variability among physicians as to what constitutes futility, with 0 to 13% chance of success of treatment as the definition of futility.20 Whatever the exact definition, we know that in all patients there comes a stage when nothing works. Although the American Medical Association and other organizations have given assurances that physicians have a right to refuse futile treatment, the legal status of unilateral DNR is not clear.21 A Houston task force22 has suggested that physicians should not act unilaterally, must obtain a second opinion, and should provide the review body with detailed case information. It has been suggested that it is appropriate to write unilateral DNR orders after a fair review of each case following the Houston model.20 Whatever the approach to this issue, the cost should not be allowed to enter the equation when a decision is made to write a DNR order. The other end of the spectrum is a situation in which the physician may unilaterally override a DNR order. It has been suggested that physicians may believe that DNR orders do not apply to iatrogenic cardiac arrests and that patients do not consider the possibility of an iatrogenic cardiac arrest when they sign a DNR order. Also, physicians may feel obliged to intervene when an illness is iatrogenic, especially when it is a result of physician error.23
We do not have simple answers to the questions of life and death. Science may one day produce human clones, delay or even stop the process of aging, and conquer death; but do we really want that to happen? As a society we might be much happier if we learn to age gracefully, accept death as the natural end of life, and stop putting artificial barriers in the path of this river as it approaches the ocean.
References
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