PGY-3 (CA-2)

A Patient’s Right To DNR/DNI

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Whether it’s an outpatient clinic visit or a prolonged hospital stay in the intensive care unit (ICU), patients who have been deemed to have decision-making capacity have the right to refuse treatment. Four criteria are often assessed by a physician in determining capacity:

  • Does the patient understand the treatment?
  • Does the patient understand how the treatment applies to his or her situation?
  • Can the patient reason out his or her circumstances?
  • Can the patient express a choice?

Often times patients can decide certain aspects of their care (yes, I’ll take antibiotics for a pneumonia) but not others (why do I need an invasive catheterization to assess the extent of coronary artery disease?) Patients have a right to refuse treatment, and this often clashes with a physician’s goal to promote wellness.

The 30-day mortality rate following surgery (or 1 year mortality after transplant) crudely reflects how “successful” an operation was. What if that patient was kept on life support in the ICU for 30 days and made DNR/DNI on the 31st day? What if a patient had cardiac arrest one week after a heart transplant with catastrophic neurological consequences requiring lifelong mechanical ventilation? Is it fair to push the family towards transferring the patient to a long-term acute care (LTAC) hospital (at least for a year) to deem the transplantation as a success?

At the end of the day, it’s really up to the patient, medical proxy, advanced directive, etc. However, I feel like in the world of transplant surgery, there might be a little more coercion to pursue long term care rather than realizing the futility of medical care. Loved ones of patients who have fallen victim to difficult post-operative courses are extremely vulnerable and need to be guided accordingly.

In a society driven by numbers and outcomes, hospitals will always try to make their metrics look good. Excellent outcomes = more surgeries = more money. But what about the family who opted to take a healthcare professional’s advice and pursue ECMO, continuous dialysis, mechanical ventilation, tracheostomy, gastrostomy, and every other conceivable modality to stay alive? Having to see their loved one in such a debilitating, often vegetable-like state every single day… when in reality… their substituted judgment may have preferred a do-not-resuscitate (DNR), do not intubate (DNI), withdrawal of care, comfort care, or some other less intense method of care?

End of life care is an extremely important facet to healthcare. Every person should make their wishes clear and legally document them in a form that no other party could exploit, because unfortunately, it happens. 🙁

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