When a DNR order can be therapeutic

The sick man expired the way he had lived—on his own terms.

By Rod Tanchanco, MD
Internist/Bear, DE

Early on, we doctors learn the anguish involved in merely preserving vital signs—not saving a life, mind you, but perpetuating the cold, objective signs of what is defined as life. I learned the difference as an intern, from a patient I'll call Mr. Scripps.

Mr. Scripps had been admitted for severe abdominal pain to another hospital, but they'd been unable to place a scope in his biliary tract to diagnose the cause of his pain. The hospital had transferred him to my hospital, hoping that another gastroenterologist might have better success.

When I first saw Mr. Scripps, he was still in moderate pain, feverish, and very weak. He scarcely spoke or opened his eyes, but he cooperated without complaint during his physical exam. The excruciating toll the disease—whatever it was—had taken on him showed in the fact that while his belly was slightly distended, the rest of him had all but wasted away.

The attending gastroenterologist had managed to place a scope after several attempts, but a definitive diagnosis required many more tests. As the days passed, his condition spiraled hopelessly and progressively downward. He had cancerous growths in his pancreas and liver, and probably elsewhere too, but a search for other sites of metastasis would be moot. Mr. Scripps' death sentence had already been pronounced.

When the family learned we could do nothing more, they decided to take him home to die. They lived hours away, however, so arranging transportation and supportive care required several days. During those days, the attendings, even the residents and fellows, left care of this hopeless case to me.

That included handling the DNR order that Mrs. Scripps requested after praying in the hospital chapel for her husband's release from suffering. I explained the DNR carefully to Mrs. Scripps, who signed it unhesitatingly.

I had just placed the DNR in Mr. Scripps's chart when a social worker pulled me aside and told me there was a commotion in Mr. Scripps' room. I rushed to his bedside; Mr. Scripps had no blood pressure.

Disbelieving, I checked his vital signs myself. It was true. Not more than two minutes after his wife signed the DNR form, Mr. Scripps had died. Had he gone only a few minutes earlier, we would have subjected him to a traumatic round of CPR, which might have preserved his life in a technical sense, but probably would have done nothing else.

In a simple, unambivalent, and bittersweet stroke of her pen, Mrs. Scripps had saved from needless pain the man she loved most. She later confided that her husband had always been in charge of his life, and that he'd resented deeply the helplessness he felt as the cancer ravaged his body.

In death, however, he was allowed to remain in charge, which was kinder than preserving vital functions. Perhaps in its own way, this too was a form of healing.

 

Carol Pincus, ed. Roderigo Tanchanco. When a DNR order can be therapeutic. Medical Economics 2000;9:144.