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

The Hospice Threat

They're building another Hospice in my town. I believe that makes about three relatively close to each other. That's the third one on about three years. It scares me. Why are we building these things so fast? Are we getting ready for something? I think we are, but no one's talking about it. I'm not even certain if anyone is thinking about it.

We are heading into a perfect storm in medical care in this country: 65+million baby boomers, general economic decline, and increased demands on our over burdened health care system. It's clear what is coming. We are going to ration much of what we did yesterday, because we don't have enough to spend on the elderly. Who will get the liver transplants in the future? Who will get the coronary bypasses in the future? I even wonder who will get their ruptured abdominal aortic aneurysm repaired tomorrow? The answer is, I believe, more obvious that many are willing to admit.

Residents are trained today to "control costs," and this effects the daily care all hospitalized patients receive. "Don't admit them if you can help it, and if you do, get them out fast!" That is the teaching mantra in today's teaching hospitals, and it is not about to end soon. It is only going to get louder.

Medicare is struggling to keep up with the expenses of the medical promises it has made to the people. It is the biggest entitlement threat to the federal budget. My guess is that the Federal Government will be forced to demand more taxes from every one's pay to support this system. Apparently, 23 percent of Medicare recipients consume 67 percent of Medicare spending, and 30 percent of this spending pays for care in the final year of life.

I have no problem with the idea of the "good death;" that is the idea that Hospice promotes. In many instances that goal is effectively accomplished. The problem is that there should be more concern that Hospice, under the current social conditions can easily become the socially acceptable alternative to appropriate care for the elderly.

Societies cannot always see clearly when individuals begin to act with the herd mentality, and I fear that is a possibility in our future. The picture of an environment with scarce resources, too many patients, and physicians that are too busy with too little of the traditional ethic of the "patient first" is developing before our eyes and we refuse to see it!

Physicians must become aware of this dangerous path, and begin the debate to maintain our obligation to our patients. There is nothing wrong with a bicameral system. In health care, the physicians must stay on the side of the patients. Let the administrators manage the expenses. We must side with the patients. The debate will be fruitful. Once doctors begin to manage the the health care dollar, we will lose the trust which is the glue that holds the physician-patient relationship together.

The patients that come to us are vulnerable, frightened, and in need. Their trust in our public promise to place each patient first, is not negotiable. If physicians forsake this promise their is no professionalism left in medical care, and physicians have become no different than merchants. There is no society that can tolerate this degradation of our professional ethic.

I have no problem with a Hospice system that is used properly. Physicians must remain aware of the danger of a Hospice that becomes the answer to our fiscal constraints. Proper medical care, and the patient first must not deteriorate.

James P. Weaver, M.D.