I am writing about Dr. Robert Brandt's column, “Let Her Go.” (EMN 2014;36:1; http://bit.ly/1rZ0NMM.) I am concerned that he applied the term and spirit of DNR improperly. This is a bad example for young physicians trying to figure out a difficult issue. For this reason, I do not believe this should have appeared on your front page.
A DNR order expresses a patient's or family's wishes in a medical catastrophe. It is not, however, a blanket request not to be treated.
The patient came to the hospital for care of her chest pain. She even activated EMS to do so. She was portrayed as independent, alert, without dementia, and even a bit vain.
Her sudden demise, if I am interpreting the story correctly, was a sudden tachyarrhythmia with hypotension. Some fluids and anti-arrhythmics, or perhaps a single shock, may have resolved this issue.
The issue was not whether to initiate ventilatory support or long-term dialysis. There was no diagnosis of terminal cancer, end-stage cardiomyopathy, or advanced dementia. There was no indication that this patient had such a poor quality of life that any prolongation beyond the time of the initial history and physical exam would be considered improper. Rather, the issue was whether an acute and unexpected medical problem should have been treated.
I am a huge proponent of defining code status in the ED and allowing patients to weigh in on their own end-of-life decisions. I, too, have watched patients die when intervention would have been inappropriate, but this case was just a bad example.
Michael Sochat, MD
Dr. Brandt responds: Whenever I write about interesting cases that occur in the ED, I go above and beyond to make sure that I protect the patient. I try my hardest to be HIPAA-compliant so that even the patient himself would not know I was writing about him. At the same time, however, I still must recreate the feelings, emotions, and spirit of each circumstance that occurs, which creates a difficult dichotomy as a writer. I want to stay true to my writing and the events but also (and more importantly) protect my patients.
In my piece “Let Her Go,” I felt I kept the story true to the spirit of the actual encounter. The piece mentions heart rate and blood pressure but not pulse ox, presence of pulses, or any diagnosis that the patient may have had. A wealth of information is left out. In the actual case, the patient would definitely have needed CPR and immediate interventions that she specifically said she did not want. I thought the requirement for CPR was inferred.
But, as Dr. Sochat accurately pointed out, if this patient just needed some fluids, it would have been a great disservice not to intervene. Perhaps a line about the patient obviously needing intubation would have made the need for CPR clearer.