* * Anonymous Doc

Friday, July 31, 2009

Another ethical question (I suppose) --

We've been dealing for the past couple of days with a woman who's not in good shape. Half-conscious, unresponsive, feeding tube, not actually living a recognizably human life. Like the 94-year-old man I wrote about the other day, the family doesn't want to acknowledge what's happening, and is refusing to sign a DNR.

"She's the leader of the family, she's always been the one in charge, we don't feel comfortable making medical decisions for her, we just want her back the way she was, you have to do everything you can, no matter what."

They don't get that she's never going to be the way she was, she's never going to be the leader of the family again, she's not even opening her eyes. And if her heart stops, and we do a full code, the best they can hope for is that she gets to go to a nursing home and live in a state of semi-existence for just a little bit longer. So I spent half the day trying to convince the family that unless she's said this is what she would want in a situation like this, it's not what anyone would reasonably want, there's no coming back from this state, and they really need to consider signing the DNR.

But then I find out that as it turns out, it doesn't really matter whether they sign the DNR or not. Because if she codes, they'll follow legal protocol and call the code, and then before anyone shows up to actually try and get her heart started again, they'll cancel the code on account of "medical futility," and say there's no point in even trying.

End result-- we do nothing, whether she's DNR or not. Now, I think the end result is good-- I don't think we should be torturing this woman any more than we have to, and, really, it's absolutely medically futile to do anything. But, gosh, is this really how the system is supposed to work? The family ends up with a phantom choice-- sign the DNR (and feel like you're signing a death warrant, to some extent), or don't sign the DNR, but we're going to act like you did anyway except for a careful technicality to satisfy the law, where we call a code, cancel a code, and get around what I assume was the intention of the rule-- to let the family decide. Why are we giving them the power to decide if it's actually no power at all? And I'm certainly glad not to have to be the one who goes out and explains to the family that after all that-- after all the debate over the DNR, after a bunch of us have all tried unsuccessfully to convince you it was the right thing-- we went ahead and didn't do anything anyway. But we couldn't do anything-- "medical futility" !


  1. Sounds like it would be frustrating. :/

    I always felt that if I ever got to that state of existence (i.e., semicomatose vegetable), I would have it written down somewhere to just have my family pull the plug. It wouldn't be fair to either my family or myself to keep hanging on.

    Just my thoughts.


  2. Well, I think cancelling the code on the basis of medical futility before someone gets there is a bit beyond the pale. Who is making the decision to cancel the code?

    In my hospital, what happens is:

    1. Family refuses DNR
    2. Code is called
    3. Everyone arrives
    4. ICU/anaesthetics refuses to intubate on the basis of medical futility -- or rather, refuses to admit to ICU, and there's no point intubating if you can't get an ICU bed
    5. Defibrillation doesn't work and the code is called off.

    It's reasonable to say: we've not bringing granny back, but for a nurse to say that it's impossible...