Partial do-not-resuscitate order, and a man in a coma

  • Do-not-resuscitate (DNR) orders are designed to alleviate undue suffering for patients who have reached the end of their life.
  • Patients can use a DNR to refuse all life-saving treatments and leave matters in the hands of providence, while partial DNRs allow patients to refuse only certain procedures.
  • In one patient’s case, his partial DNR may have caused him even more suffering than he might have expected.

In a case published in the journal JAMA Internal Medicine, here’s Leonard’s story.

Leonard was 77, with widely metastatic colon cancer. One day, his heart stopped.

When doctors tried to save him, they found out about the partial DNR he wrote, back when his condition was better.

Similar to patients’ right to seek medical help, DNRs represent patients’ right to refuse such help. In general, DNRs let doctors know that the patient refuses life-saving treatments. For instance, I would write a DNR when I’m well, so that I can refuse treatment should I become unconscious.

A partial DNR is an order for the doctor to save the patient, but avoid certain procedures. For example, ‘do everything but withhold intravenous (IV) medication’.

Leonard’s partial DNR was “everything but intubation”. Intubation is a procedure where a tube is inserted into the wind pipe to deliver oxygen directly into the lungs. It’s not always placed permanently.

This might sound perfectly harmless, but the results were anything but.

Over the next half an hour, doctors tried to save Leonard with chest compression and an oxygen mask. Miraculously, they managed to restart his heart, but he went into a coma likely because his brain couldn’t get enough oxygen without an intubation tube.

Leonard’s family then stepped in and asked doctors to keep him alive by any means necessary. Without intubation, of course.

Leonard never came out of his coma. He stayed in the intensive care unit (ICU) for two weeks. During this time, his liver struggled to function and his kidneys failed. Before he passed away shortly after, he was on dialysis 3 to 4 times a week.

Bottom line

  • It’s hard enough for doctors to predict what would happen to a patient towards the end of his/her life, much less for the patient him/herself.
  • To have a partial DNR that can anticipate most situations, the degree of complexity needed means that no one can read it fast enough in an emergency to respond.
  • As death is a natural part of life, end-of-life care should be just as important as life-saving treatment. Find a doctor you can trust, and make sure you have an open and honest conversation about DNRs.

Source case report: Rousseau P. JAMA Intern Med 2016;176(8):1057-8. A paid subscription may be required.

Photo adapted from original by A. Zirma, used under license.

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