Resident physicians as the key to Do Not Resuscitate orders

At last month’s ASCO Palliative Care conference in Boston, one of the presentations was a survey, done by resident physicians (doctors 1-3 years out of medical school, doing hospital-based, post graduate training) at Tufts Medical Center.  The topic: what their fellow residents thought about conducting conversations with patients about Do Not Resuscitate (DNR) orders.

Some background:  most of the time, these conversations would arise in the first encounter between a patient, being admitted to the hospital, often if not usually through the Emergency Room, and the young doctor whose turn it is to accept a newly-admitted patient for care.  The doctor certainly does not know the patient at all, much less well, before that, and the scene can be hectic.  But for a patient who may be seriously ill and near the end-of-life, the doctor should know what the patient’s wishes are about end-of-life care.  That knowledge is often largely for the purpose of managing the resources—particularly space in the intensive care unit—of the hospital.  It can also be needed for the hospital to document meeting a metric about quality.  If the patient has an advance directive already, the information may not be immediately available to the resident physician.  Or, the patient may never have thought about it much, or had a conversation with his or her “regular” doctor—if he or she has one.  I submit it is not an ideal situation.

In the survey in question, responding residents said overwhelmingly that they considered these conversations their professional duty, and that they considered themselves qualified to conduct the discussions.  Moreover, many of them thought that they were MORE qualified, or at least in some way in a better position, to do so than more senior physicians.  I found this last point astonishing.  It was not clear to the presenters of the work why it should be.  One can speculate: perhaps the residents think that, as the point people for in-hospital care of the patient, they are best positioned to superintend the management of the hospital episode (although the senior, “attending” physician properly shoulders that responsibility), or perhaps they thought that they are more up to date about the data regarding the likelihood of surviving in-hospital arrest (the prospects are generally dismal).

Many conversations about how to tell whether doctors are doing “too much” or “too little” at the end of life take on the character of autonomous patient as consumer, with the doctor taking the stance of “the customer is always right.”  I wonder if some of that may not be operating in the reluctance, that I commented on with horror in my post a couple of weeks ago, of some palliative care doctors firmly to rule out physician-assisted-suicide or euthanasia as part of the proper scope of their practice.  But of course, a countervailing theme in these end-of-life conversations focuses on how doctors may push, or at least “nudge,” their patients toward more treatment than is likely to be of benefit or less treatment than might be good medicine.  And in the case at hand, there are fairly strong incentives for resident physicians—who, in the first approximation, are employees of the hospital—to shepherd hospital resources and achieve hospital metrics urgently, while being frankly too harried or simply in the wrong relationship to the patient to be able to give proper attention to the overall proper care of all the patient’s needs.  And, frankly, in the hospital, a patient who is “DNR” may not pose as heavy a workload for an (often exhausted) intern or resident than would be the case if they had to be shepherded to and through a demanding course of intensive care.

I am sure that most resident physicians conduct these conversations with considerable care and wisdom, certainly all the care and wisdom they can muster.  Placing limits on intensive treatment is often “appropriate,” to trot out that tired, overworked word—that is, in-hospital resuscitation is frequently, even usually, poor medicine.  But there are incentives to “nudge” a patient in the direction of less treatment.  And the middle of the night in a crowded ER is not exactly the venue for an optimal discussion of the topic.   We need to do better.

 

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Dr Vincent ChiaMatthew Cote, MDCarol J. Eblen Recent comment authors
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Carol J. Eblen
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Carol J. Eblen

It appears that you do not address the fact that so often Medicare/Medicaid patients become “charity” patients for the hospitals when CMS/Advantage Insurance refuses reimbursement under Part A and Part C Medicare/Advantage Hospital Insurance Coverage. Do you believe that Medicare/Medicaid safety nets are being transitioned to “managed care” and “managed death(Hospice)” because of the influence of the BIG private Insurance Companies who earn great profits because of lucrative contracts with CMS to deliver Medicare/Medicaid health insurance to the public. Obviously, the residents of Hospitals have a conflict of interest and are aware that the very elderly/diabled on Medicare/Medicaid may become… Read more »

Matthew Cote, MD
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Matthew Cote, MD

I appreciate the intent to delve into this all too common problem. I might suggest that the motives being ascribed to the resident physicians, though, may not be as nuanced as the posts presume. The reality of resident physicians perspectives lies not so much with any real interest in the cost of the medical care in question as it does to the perception of the resident on the appropriateness of the care. Specifically, it doesn’t cost the resident anything financially one way or another. The currency that is most important to the resident is their time. This, of course, is… Read more »

Carol J. Eblen
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Carol J. Eblen

It is my experience that when elderly/disabled Medicare patients are admitted through Emergency to Hospital care, they are targeted for DNR Code Status by the physician who is an employee of the hospital. The Emergency Room physician may be in a contract status with the hospital but the legal duty of this physician is to diagnose the emergency problem and keep the patient alive and stabilized as per EMTALA to determine a plan of care. To suggest that the resident physician should have the right or authority to determine what is “appropriate” end-of-life care and to influence (and even be… Read more »

Matthew Cote, MD
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Matthew Cote, MD

In my initial reply to this thread, I clearly did a poor job of communicating my thoughts on this topic, so I will briefly clarify. I recognize and share your concerns, Carol, regarding the conflict of interest that comes when medical providers have a personal financial stake in the treatment decisions and plans of their patients. As a physician, I see this currently in the primary care realm where HMO patients have restrictions placed on their medical care by their doctor, who is financially incentivized to limit such expenses. However, as a practicing ER physician of 17 years, I have… Read more »

Carol J. Eblen
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Carol J. Eblen

Thank you for your response, Dr. Cole. I understand what you are saying. I don’t believe that MOST physicians would violate ethics and law and the trust of their patients by extrapolating covert or overt(default) UNILATERAL DNR code status into the charts of elderly/disabled Medicare/Medicaid Hospital patients for the sole purpose of shortening life to cap costs of further treatment that will not be reimbursed to the hospital because of existing CMS/Advantage Insurance reimbursement protocols. However, because of my personal experience with the unilateral DNR, I do know that some physicians and hospitals do feel justified in doing this because… Read more »

Dr Vincent Chia
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As a physician practising in Singapore, and a keen student of bioethics and philosophy, I would like to add my two cents worth.

In general, at least in Singapore, physicians do not discuss DNR issues with patients upon admission. Also the management of resources might be construed as part of distributive justice, physicians are bound ethically to consider autonomy, beneficence and nonmaleficence as well.

Each DNR is decided upon on a case-by-case basis, although I admit that there are cases whereby limited resources or patient’s financial limitations might have a modest impact upon the final decision.

Interesting discussion thus far.

Thanks for the post!