There's no protocol in the United States for the process of making a patient DNR. I don't mean the simple act of writing "DNR-CC" (Do Not Resuscitate, Comfort Care) in the chart after a long discussion with family members. What happens next? Do you open up the "death playbook" and run the offense with morphine and benzodiazepines? It doesn't exist. Palliative intervention varies from hospital to hospital, from doctor to doctor. It's something you make up as you go along.
As a surgeon, I get involved in futile cases more often than I would like. As the population ages, we find more and more 80-90 year olds in ICU's who develop acute abdominal emergencies, such as ischemic bowel, toxic megacolon, neoplastic colon obstructions, and perforated ulcers. Often, they show up without family or contact information. Dementia and/or toxic encephalopathy precludes an honest discussion of how aggressive the level of care will be. The patient will die without an operation. However, the concomitant coronary artery disease, COPD, and heart failure make any surgical intervention fraught with hazard. What do you do?
Sometimes surgery is life saving. That can't be denied. I've seen it with my own eyes; elderly patients smiling as they are wheeled out to the rehab facility, a week after being on death's door. There are few things as gratifying in a general surgeon's practice. Another year on earth. More time to be spent with loved ones. Some aren't ready to be done with this thing called life.
But there are others who don't do well no matter what you do. You can do the perfect operation in an expeditious manner and it's all for naught. They won't wean from the vent. They go into heart failure. Multiple organ failure develops. An inevitable, ineluctable downward decline hurtles them toward oblivion despite your best efforts. The futility of the situation eventually becomes obvious to all and the time comes for "the talk" with the family members.
I've had two patients in the last month who presented in extremis with peritnotis and/or ischemic bowel. One was an open and close case; entire length of small bowel gangrenous. The other was an incarcerated hernia with dead sigmoid colon that had perforated into the peritoneal cavity. Both patients were octogenarians. Both had lived full, enriched lives according to the respective families. It was time to say goodbye.
But how is this done? We agree to withdraw supportive care. Antibiotics are stopped. Vasopressors are halted. Directives are given not to run a code when the patient starts to deteriorate. There are no chest compressions. No epinephrine. The primary objective is palliation. Make the patient comfortable. In this synthetic environment, where some semblance of life is propped up with machines and tubes and drugs, it isn't ethical to merely "turn everything off". They've decompensated beyond the stage of self-sustaining life. Unplugging everything and stopping all the drips is about as cruel a thing as I can imagine. I never terminally extubate a patient. There's nothing more gruesome than watching a patient suffocate after terminal extubation. A wise old nurse made me experience it when I was a resident. No reason to pull that tube out. The dead bowel or the fecal peritonitis is going to stop the heart soon enough. No reason to expedite the death with unnecessary agony.
Here's my ICU orders for these cases:
-Do not extubate
-Morphine 4 mg IV q 15 minutes
-Propofol drip titrated to complete sedation/unconsciousness
-Turn down the sound on all monitors.
People don't die on cue. Sometimes it happens right away, as soon as the levophed is unhooked. But not always. I've seen patients linger for hours, heart rates in the 30's, blood pressure barely registering. The families are in the room, keeping vigil, together for the last moments of the loved one's life. The patient is peaceful looking, sedated, unrushed on his journey toward death. We cannot control the inevitable end, but we can control how gently we allow these poor souls to land.