Substituted judgment and resuscitation: a case

A 65 year old patient with advanced airways disease is treated with non-invasive ventilation but ICU decide that full mechanical ventilation via an endotracheal tube is not justified. The junior doctor on call discusses DNAR with her, but she indicates that she would like to be resuscitated. In the morning I am called to the ward where her husband and family await. He saw her survive a similar illness three years ago, including prolonged ventilation via a tracheostomy. After discharge he retired early from his job to focus on her convalescence, and is proud that the care that he and the community team have provided saw her exercise tolerance improve from just a few yards on discharge to 100 yards. She remains significantly debilitated.

 

 

I discuss her condition, and raise the question of resuscitation. In his mind there is no question – she must be resuscitated. I explain that her very poor baseline lung function, and the severity of her current infection, mean that attempts to restart the heart are almost certain not to work. I do not mention that prolonged ventilation in ICU has been vetoed already. He insists, and refers to doctors who said the same last time, only to be proven wrong. But this is different, I explain, she is weaker. He will not assent. It is not appropriate to go on and on, and I leave him so that he can back to her. I cannot fill out the DNAR in the face of such emphatic disagreement, but I know that for the patient it is right. I suggest that we speak again in the afternoon, and that if there are signs of deterioration I will have no choice but to make her DNAR. I reflect that even if he makes a formal complaint, I must do what I think is right for the patient.

  

We talk again. He emphasises that she would want to be resuscitated. But she has worsened, and I sign the DNAR. I discuss it with colleagues, and the concept of the ‘short code’, or limited resuscitation, or, in my view, a fake attempt, is raised. I find that option inappropriate, on the basis that it is motivated by concern for the relative and the doctor, but cannot be interpreted as being in the patient’s interest.

  

The patient deteriorates further, and I sit with the husband again, for the last time that day. He begins to see the truth of the situation, and no longer objects to the DNAR order. The patient dies relatively peacefully next day. So what does this anecdote demonstrate?

  

A DNAR decision was proposed, but the patient’s closest relative, the one who would know her true preferences best, objected to this. He knew that she would have wanted to be resuscitated, having come this far, having proved doctors wrong before. But I remained steadfast, and spent a lot of time talking him through my reasons. In the face of ongoing deterioration he finally removed his objection. I knew that there was a risk that he would make a formal complaint, and this caused me considerable discomfort. But circumstances, and my unwavering position, in the end persuaded him. Autonomy, and substituted judgement, were overruled.

 

 

The truth is, resuscitation is a treatment, and no doctor will provide a treatment unless it has a good chance of working. The challenge we have, as healthcare professionals, is that of communicating how ineffective that treatment is likely to be in so many cases.

 

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