Sine qua non

A friend of mine questioned my ICU DNR habits, because in reality, there are some patients that turn around, and for the most part, when DNR orders are written, patients get less care. I wouldn't say poorer or substandard. It's not true. Less care, yes, because we focus away from curative things just by the nature of the DNR order, almost reflexively. It's not overt. It's simple things, like the knowledge that if we take out the ET tube, we're not putting it back in.

I feel very strongly about this, and I think there's a good sine qua non for a patient that needs a code status change: if I can go home and sleep at night and feel good about the result, even when the patient's dead, then that's a good DNR. I did my best, and life is what it is.

If I feel there's still an avenue to pursue or a treatment untried, then I'll try it. If a patient's in the ICU, the rule I use is that there's nothing I won't try in the first 72 hours.

But if it's >72 hours and the patient's knocking on death's door, I'm willing to say I've done my best. And to this day, I only have one regret. It was a patient in neutropenic sepsis. By the time the patient got to the unit, the BP was in the 50's and was seconds away from coding. I couldn't get the patient through to the morning. If I can't get a patient 24 hours, just one damn day, then what am I doing?

The patient hit the unit at 11PM. I asked for a code status change at 3AM. I asked to withdraw care at 5AM. And I went home at 9AM, and once I got home, I started cursing and throwing things. Just 24 hours. I couldn't even do that. What about Xigris, different antibiotics, an antifungal, more aggressive fluids? What I did wasn't malpractice. I took excellent care of her. I doubt that there's anything I could've done to save her. But I didn't care about saving her. I just wanted to give her one more day.

So I think when it comes to DNR, you need to find your line in the sand. Whatever you can live with.