The Meaning of DNR

I had a provocative conversation last week with a Hospitalist. We talked about the meaning of DNR. I had always thought it meant if the patient stops breathing or goes into cardiac arrest, that one would not try to "bring her back" by external chest massage, electro shock, and iv drugs. The person I was talking with had a different interpretation of this term and stated that, "it means no heroic measures." I have thought about this for quite some time now, and it is a bit disconcerting.


What does "no heroic measures" mean anyway? Who determines what will be "heroic?" Heroic to one might be "necessary" to another. This is of concern, because the person who said this is a recently trained physician, a younger doctor. Is this what they are trained to think these days? I would like to examine this concept more closely.

In a recent post of mine on this blog-The Hospice Threat, January 19, 2009- I discussed my concern with the increasing population of elderly, decreasing dollars for health care, and overworked physicians, that the drive to treat the elderly will diminish. "That old guy has a pretty bad sprained ankle. Maybe we should just let him go,"is a phrase I have used to illustrate this probable future shift in physician behavior.

It seems to me that "no heroic measures" potentially is a much broader interpretation of the DNR concept. Is it heroic to treat a urinary tract infection in a 85 year old patient who has had a previous stroke and is hemiparetic? And how about using antibiotics to treat pneumonia in a renal failure patient with a previous amputation, cardiac disease, and a previous stroke, is that heroic? The problem with "no heroic measures" is that it is vague enough that it opens the door to RATIONING. This rationing, unfortunately, will be used in a "final" sense.

We don't like to say the "R"word, but it isgoing to happen; the question is how? Will certain services be denied? Will certain services be prohibited? My guess is that certain things will not be paid for, and others will not be available. The critical issue is that the behavior of physicians should not be influenced by societal pressures. I'm afraid that, in the future, the societal influences on physicians behavior will be covert and subtle. Physicians will just not do what they did twenty years ago to save an elderly patient.

I see this different understanding of DNR as another wedge into the physician-patient relationship, with the potential to weaken the physician's classical obligation for the care of the patient. This is yet another example of forces diminishing our Professionalism. With the financial pressures on medical care, this is just another brick in the foundation of rationing.


James P. Weaver, M.D.,FACS