Common things occur commonly, but as a group uncommon things are also frequent. Exactly how frequent they are we do not know. We do know that our estimates are biased under-estimates. Similarly, randomised control trials are not as unbiased as we would hope….
I had an 83 year old female who presented with a large, rapidly progressive, intracerebral and intraventricular bleed. She was on warfarin and presented an hour after a sudden collapse already persistently comatose. The extent of the bleed made it inoperable.
In situations where an attempt at resuscitation would be futile we decide and document that when cardiac or respiratory arrest occurs, it won’t be treated. Such decisions preserve resources, emotions and patients’ dignity. Making such decisions can be extremely difficult especially considering that family and caregiver sentiments are not medico-legally relevant. We like to get agreement from those close to the dying patient but initiating or terminating treatment is not a democratic process. Wide agreement helps share the emotional burden.
DNAR orders are, however, not binary: there are many interventions between doing nothing and providing pressor support with IPPV. Bodies need fluids, electrolytes, calories, vitamins, trace elements, oxygen and movement. They also need to get rid of wastes. Medication related side effects and adverse reactions need to be managed and disease complications need to be anticipated and prevented or mitigated.
The medical registrar to whom I referred agreed that death was imminent and inevitable; he nevertheless prescribed vitamin k as anti-coumadin. I asked why and he said that she may have been continuing to bleed and that the treatment would stop the bleeding. He felt morally or ethically obliged to close the gate after the horse had bolted. If the treatment would make any difference, it would serve only to delay death; it would not reverse the coma, relieve pain or in any other way make dying easier.
I pointed out that not giving vitamin k could – not definitely would – hasten death and that it was an acceptable omission similar in essence to treating cancer pain with high dose opiates that ultimately hastened death. In both cases, death was not an aim, but the end of an inevitable process. He remained unconvinced.
As humans we are inconsistent. For the most part it does not matter. In matters such as these, I believe it does.
Should people die at home or in hospices or in acute care hospitals? Who should decide? When should the decision be made? What should inform it? And when should it be reviewed?
This is a truism. This is a falsehood. A falsehood is not the opposite of a truism.
Simple statements are easily profound because they invite deeper engagement to lend them gravity. And truths are often simple.
We know that all that glitters is not gold but parsimony has proven utility which is why we need, consciously, to guard against it.
Appearances are everything.
We react to aggression and fear automatically with deeply ingrained biological responses. They are faster and more immediate than anything related to conscious thought.
