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Monday, July 30th 2007

DNI/DNR

I rolled through my first month on the wards. I’ll wait for the applause to die down.
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I’ll echo virtually every medical student who has come before me in saying that it is gloriously better than the hours upon hours in the classroom that constitute the first two years of school. There is something, right off the bat, that has disturbed me and I get a feeling talking to physicians that what I’ve seen in my first month is not somehow isolated to my first facility or medicine team. What I’m a little peeved about is the hard sell of the DNI/DNR choice.

A made up situation: A patient with lung mets who develops recurrent effusions and keeps bouncing back for basically symptomatic thoracentesis. His/her prognosis is terribly poor and indeed if it was me I’d would think the best place for me would be hospice and I’d probably want to be DNI/DNR. But it isn’t me. If the patient is informed, as best as possible, and wants to be full code, doesn’t want hospice…why is that such a problem.

I understand that as health care professionals they’ve seen the consequences of full interventions on these patients. They’ve seen the futility and the actual prolonged suffering of such and they understand it in a way that just talking to the patient probably cannot relate. But shouldn’t it work that you try your best to convey your opinion and the consequences of both choices and then respect the patient’s wishes?

Do you really need to be frustrated back in the team room? Do you really need to revisit the issue with them everyday? These sales pitches I hear made to some of these patients go far beyond advice, they’re approaching car salesman level.


What Is It Going To Take To Get You DNR?

There is real futility in these choices and it burns me inside that these patients sometimes choose prolonged suffering for themselves. I know these physicians think they’re doing what is best for the patient but paternalism dropped out of vogue a while ago.

I’m also disturbed by the contention that futile full codes or hospice refusal wastes health care resources. He should be in hospice, then we’d have another bed. This health care system is the least efficient in the western world. I don’t think these patients represent a real comparable drain on the system.

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