2001. Case1 DNR order



Mrs. A is a 58 years old lady.
She is suffering from breast cancer 4 years ago and now in the terminal stage with multiple bone metastasis. Her condition now is stable by antineoplastic drug which is given to her in periodical hospitalization, and the pain control by morphine etc.
It was told that radical cure medical treatment is impossible to the patient, so owing to the patient's hope the DNR (Do Not Resuscitate) orders was written "If the patient is suffering from cardiac or respiratory arrest, the CPR is not done".
However, she is now suffering from severe streptococcal pneumonia perhaps owing to leukocyte reduction by the side effects of an antineoplastic drug.  The medical team think streptococcus pneumonia should be treated  by an antibiotic drug, using a respirator since the blood gas also got worse suddenly.
The patient became unconsciousness owing to low oxygen state. And it is hard to check of her intention to use the respirator.
So her family members, two daughters in twenties, (her husband has passed away by the lung cancer two years ago) were called to come to the hospital and make the proxy consent. They say that they want to respect mother's hope as much as possible, but if it the medical treatment which may make condition improve, they want to use the respirator.

Now, what should the doctor in charge to do?
1) Is this situation DNR order (orders not to resuscitate) is indicated?
2) In Japan, once the respirator stated, it is hard to withdraw the respirator if the situation is deteriorated. I think it is owing to the fear of the doctors to be sued they let the patient die.
In the american textbook of bioethics "withhold" and "withdraw" the respirator is the same thing. Is it the global standard all over the world.



Commentary



First, I think that from a US point of view, one could characterize this
case as the physician having simultaneously agreed and not agreed to respect
the patient's wishes for the DNR status. I say this because one could have
easily anticipated this outcome. What, after all, do terminal cancer
patients die of?  Pneumonia is the expected and one might even say "normal"
way that many such patients will eventually die. This woman has asked to be
allowed to die without having her dying process prolonged by certain types
of medical interventions. The physician agreed to the DNR order, but what
happened later illustrated the fact that the physician really did not agree
with the concept or the fundamental idea that underlies the DNR order. So
there is a sense in which the DNR order was fraudulent. It would have been
more honest for the physician to say to the woman, "Unfortunately, our
Japanese system of medical care believes that if you are in a hospital, and
we think we can correct what is wrong with you, we must try to do this, and
so I cannot promise not to put you on a ventilator."

Second, you ask about the ability to withdraw the ventilator later once it
has been started. Virtually all the "official" statements of the bioethics
community in the US agree that withholding and withdrawing the ventilator
are morally equivalent acts, and they also advocate starting the ventilator
if one is unsure, based on the idea that one can always stop it later, lest
patients who might benefit dramatically from the ventilator be denied a
trial of therapy. However the "official" statements of bioethicists and the
feelings of average physicians do not always agree. A recent survey
published in the Journal of Medical Ethics in England (I have packed up all
my files to move and do not have the reference on hand) showed that many
physicians and nurses in the US and the UK still feel fairly strongly that
it is morally worse to stop a ventilator once begun, than not to start it in
the first place. Two scholarly papers have been published in the last few
years attempting to demonstrate that maybe these average physicians are
correct and the bioethics community has been too hasty in reaching its
conclusion of the moral equivalence of withdraw-withhold. But in my personal
view the reasoning of these two papers has been weak and I do not think many
bioethicists have been convinced.

The law in the US is today more clear-cut, I think, and few physicians are
under the impression that they will be sued if they were to stop a
ventilator in a patient who had clearly indicated previously that that was
her own wish. Indeed of late, the more common lawsuit would have been
against the physician who STARTED the ventilator AGAINST the patient's
stated wishes.

Howard Brody, MD
Michigan State University



Dear Masashi,

I think the case is interesting.  Thank you for sending it to us.

I am sending a copy of your letter and my reply to my mentor in clinical
ethics, Prof Shimon Glick, because this case might interest him.

I do not think the DNR order applies in this case because the DNR order
referred to cardiac or respiratory arrest.  But this is a hypoxic state
due to an unforseen development.

I think that culture is also important.  So far as I understand Japanese,
the family's wishes are extremely important.  I should have thought that
in Japan, the family's decision to ventilate is almost like the patient's
own decision.  Is this true, or am I mistaken about Japanese thinking?

So far as witholding and withdrawing are concerned, here in Israel there
are religious authorities who argue that withdrawing is like killing but
witholding isn't so bad.  The implication is that it is better to withold
if you think you will most likely have to withdraw soon afterward.  I
believe exactly the opposite.  One should give the patient a chance, start
treating, and be ready for the possibility of having to withdraw treatment
later.  This is what I would do in the present case.

However, I would be very much against ever withdrawing treatment in cases
like this unless there had been a clear directive to that effect from the
patient.

In Israel there is now a law pending in the Knesset (parliament) to allow
withdrawing ventilation in certain cases.

Enjoy your rainy season.  It is very dry here, usually no rain at all in
Israel during the summer. But I am travelling to India in August for our
humanitarian medical project (Mother and Child Health Education for Dalit
("untouchable") Mothers) and it will be the monsoon season.

Frank (Yeruham) Leavitt, Ph.D.
Chairman, The Centre for Asian and International Bioethics
Faculty of Health Sciences
Ben Gurion University of the Negev
Beer Sheva, Israel



Dear Masashi,

Thank you for sending this interesting case.
It is a good illustration of the need for good doctor-patient
communication when the patient is lucid and able to talk. In the best of
situations, the physician might indicate that the patient could lose
cognition due to the advancing disease---or due to medications that are
being used to slow the disease. Although the patient requested Do not
attempt resuscitation if she lost cognition due to the disease, she
apparently did not discuss the latter. (The difficulty of understanding
just when Advance Directives apply has been used as an argument against
them by some)
Since in this case the patient's intent is unclear, and the family reqests
that the ventilator be used, it seems appropriate to honor the family's
wishes---as you and I have discussed in the past that in Japan---it is
more of a family decision than an individual decision in many cases.
Later, if it appears the patient will not recover to her earlier baseline,
will remain in a PVS, or recover consciousness only to experience great
pain and little benefit from her treatment---then the family may wish to
reconsider (involving the patient if she is able) and it is ethically
legitimate to discontinue aggressive treatment that is unwanted by the
patient-family. This is also supported by laws in the USA and I believe in
Japan---but you are more familiar with Japanese law.
Good wishes to you.  I have stepped down as Director of Counseling at the
UW, but continue at 40%time teaching medical ethics.

Dr. Thomas R. McCormick
Box 357120 UW School of Medicine
Seattle, WA 98195-7120
visit our web site at: http://depts.washington.edu/mhedept/



Dr Shirahama:

Your latest case of the 58 year old female patient with end-stage breast
cancer raises interesting questions.
One central issue is what is the obligation of physicians as regards medical
care: is it to offer patients (or their families) all possible options or is
it to offer them "reasonable" medical options? Both CPR & intubation in this
case would seem to be inappropriate given the severity & irreversibility of
the patient's condition. She would most benefit from an acknowledgement of
her terminal condition & an agreement that the goal of treatment is to keep
her comfortable. The obligation of physicians is not to do "everything" but
to do what is reasonable. What is reasonable is relative to what one can
actually do (this is evidence-based medicine) & what the patient would want
(this is patient-based medicine). One can always "do" things, the art of
medicine is knowing when not to do things. The artful clinician should work
with this family to help them accept the sad reality of the patient's
situation.

Philip Hebert
Assistant Professor, Family Medicine
Sunnybrook Health Science Centre
Clinic Office: A102, SHSC, 2075 Bayview Avenue
Clinical Ethics Centre: Room 228b, SHSC
Toronto



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