I’ve been thinking about this a lot lately, so I thought I would write a blog about it! I’d love to know what you think
Being part of a healthcare team for a patient is an honor and a privilege. A patient invites you into their lives and shares their most intimate health information with you. Sometimes they share personal conflicts, family and financial troubles, fears, and failures. They not only trust you with that information, but they rely on you to help them make decisions in their best interest.
The four pillars of medical ethics are beneficence, non-maleficence, justice, and autonomy. Beneficence is the commitment we all share as medical providers to “do good”. Non-malefience is the age old oath from Hippocrates we take to “do no harm”. Justice is to treat all patients fairly and with the same consideration you give to everyone regardless of race, religion, age, financial status, or even your personal opinion of the patient. Justice stands for equality in treatment. I struggle with this one because so much of the medical system is unjust. You get better healthcare when you have insurance, when you live in a developed country, etc.
Autonomy is the ethical principle that each patient has the right to make their own medical decisions. Medicine has a long history of being quite paternalistic. You do what the doctor says without question. I am a STRONG advocate of patient autonomy. I truly believe that a patient should be able to make their own medical decisions and do what they want. It’s their body, their life, and they have to live with the consequences of the medical decisions they make. I should not be the one to make those decisions, because in spite of my medical knowledge and experience, I know nothing about an individual patient’s life and what each medical decision might mean specifically for them.
We had a practice session with standardized patients during orientation last month, and one scenario involved talking about code status with a patient. Code status means whether the patient would like to be fully resuscitated in the event of cardiac arrest (Full Code) or whether they would like to let nature take it’s course should their heart stop or should they stop breathing (Do Not Resucitate/Do Not Intubate). Clearly, the code status differs greatly between patients depending on their age and health.
If I were to suddenly drop dead from cardiac arrest, I would want everything done- CPR, cardioversion (shocking my heart), and even putting a breathing tube down my throat. I’m 26 years old and the likelihood of me recovering from a catastrophic event like that is fairly high.
If a 90 year old with end-stage lung cancer were to be found without a pulse, the likelihood of them surviving a code is extremely low.
In fact, studies have shown that only between 10 and 20% of patients who code in the hospital end up leaving the hospital alive. An even lower number leave without any long term neurologic deficits.
When I had the conversation with the standardized patient about code status, she had metastatic breast cancer. It was my personal opinion that she should be DNR/DNI because the probability of her surviving a code is so low. It’s possible that if she were “full code” she could die in an ICU with a breathing tube down her throat, heavily sedated and unaware of her surroundings.
But when she asked me, “What would YOU do?” I told her, “I can’t answer that for you. That is your decision to make”. I told her that because I believe so strongly in patient autonomy. I don’t know her background and I shouldn’t make that decision for her. Throughout all of medical school I always believed it was wrong to tell the patient your opinion.
Well, I have completely changed my mind. I have come to believe that now that I am a doctor, I have medical knowledge and clinical experience that make my opinion worthwhile to patients. While I would never try to coerce a patient into what I thought, I think there is value in what I would do. I think patients come to their doctors for medical advice and I now realize that you can respect patient autonomy while still telling the patient what you think or what you would do.
For every new admission to the hospital, I ask them about code status. I now find myself having different conversations depending on what I think clinically would be best for the patient. I’ve had a few healthy patients in their sixties ask about DNR/DNI. They tell me they don’t want to “be a vegetable.” I explain to them that sometimes there are reversible causes of cardiac arrest or reversible things necessitating intubation. I’ve seen patients come in septic and need to be intubated. After a few days of antibiotics they are extubated and go home. Had that person been DNR/DNI, that would have been it for them.
I’ve also found myself comforting patients who decide to be DNR/DNI by telling them that in my experience I think that is a good decision for them. I recently had a patient who was originally ‘Full code’ but suffered a devastating stroke. We had a family discussion in the hospital and changed them to DNR/DNI.
I think that having these discussions can help patients chose a plan of care that is right for them. It can help decrease the number of people who die in the ICU (did you know that 1 in 6 people in the USA will die in the ICU?). It can help decrease costs spent prolonging life that the patient might not have even wanted. It can also help comfort patients and their families.
I’m glad that I’m learning how to respect patient autonomy while still giving advice. Counseling patients truly is an honor and even though I’m a brand new doctor, I hope I can contribute to their care.
What do you think? Do you want your doctors to tell you what they think?
Have you ever had to discuss code status with family members or friends?