The Long Road Ahead

DNR misconceptions

A few interesting things today. Those of us starting with internal medicine rotation brushed up on our sparse knowledge of heart sounds (murmurs, rubs, gallops), acid/base balance, and salt/water balance. Half of the group then did an EKG lab while my half of the group had a session on DNR/DNI orders (do not resuscitate, do not intubate).

Normally, when a patient’s heart stops (often a primary component of the legal definition of death), the medical team “runs a code” on the patient in an attempt to resuscitate the individual. This involves CPR, drugs, possibly a breathing tube, and the infamous defibrillation paddles as seen on ER. A DNR would allow a patient, typically a terminally-ill patient, to refuse such treatment in order to pass away peacefully. Similarly, a DNI would allow a patient to refuse intubation (having a breathing tube placed) since some patients understandably do not wish to live if it means being tethered to a machine that breathes for them.

There are many misconceptions about DNR/DNI and about resuscitation in general, some of which I believed until the session, so I thought I’d share those here. First of all, it’s important to note that patients who request a DNR typically do not do so because they are in physical and emotional pain and/or wish to die sooner rather than later. Rather, the primary reason behind seeking a DNR is to ensure their passing is peaceful and calm, surrounded by family and friends. The alternative, the seemingly frenzied chaos of resuscitation, is something they would wish to avoid. Another common misconception is that of the success rate of resuscitation. What percent of patients with cardiac arrest (heart stopping) would you say are successfully resuscitated? Look in the comments section for the answer. I found that quite surprising. It’s also important to note that that is the percentage that survived the resuscitation. Even fewer patients survived to discharge. The success rate is even lower for individuals over 70 (see comments). And of those individuals over 70 who are successfully resuscitated, half of them are left with permanent brain damage. The rate for patients with end-stage kidney disease and stage IV cancer are lowest of all (see comments). Given these abysmal success rates, it’s a little clearer why patients near the end of their life may opt for a DNR. Interestingly, an informal study found that the common misconceptions on the success of resuscitation may stem from TV shows. The investigators watched medical TV shows (watching TV – that’s my kind of research!) and found that on ER and Chicago Hope, the resuscitation success rate was around 67%. For Rescue 911, the success rate was 100% (it’s all success stories).

On Monday I start my medicine rotation. Having clinical rotations during the second year (as opposed to the third year) is a primary factor behind my decision to come to Duke. I know that many other programs may criticize this abbreviation of the basic science curriculum and early entry into the clinical world. However, as many former students have pointed out, the learning is so much easier when the condition of interest is not buried in the pages of some textbook but when it is conveyed to you by a person who lives with that condition every day. The internal medicine clerkship director gave us a great quote by Sir William Osler, a prominent figure in medicine and arguably the founder of American and Canadian medical education. He puts it a bit more eloquent than I can.

“My firm conviction is that we should start students beginning their clinical experience at once on their road of life. Ask any physician of twenty years standing how they have become proficient in their art, and they will reply, by constant contact with disease; and they will add that the medicine they learned in the schools was totally different from the medicine they learned at the bedside. In what may be called the natural method of teaching, students begin with the patient, continue with the patient, and end their studies with the patient, using books and lectures as tools, as means to an end. Students start, in fact, as practitioners, as observers of disordered machines, with the structure and orderly functions of which they are perfectly familiar. For beginning students in medicine and surgery it is a safe rule to have no teaching without a patient for a text, and the best teaching is that taught by the patients themselves. The whole art of medicine is in observation, as the old saying goes, but to educate the eye to see, the ear to hear, and the finger to feel takes time, and to make a beginning, to start a student on the right path, is all that we can do. We expect too much of students and we try to teach them too much. Give them good methods and a proper point of view, and all other things will be added, as their experience grows.”
- Adapted from William Osler: "The Hospital as College"

posted by Ashish @ 10:48 PM