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Treatment or No Treatment?

Posted Jan 07 2009 6:04pm
I have always found myself stuck in a difficult position in medicine. But I always believe that I could only do what I feel is right and best for my patient. Of course, I have to ensure that whatever I do, does not cause more harm to my patient. During the final months of medical school training, I began to accept that I am the person in charge of making decisions, that could either safe or kill a patient! Shite!

Last night, I found myself in such a position. A poor elderly lady with dementia and has been registered blind, was admitted to the hospital with a chest infection. Unfortunately, things turn for the worse, when she developed kidney failure and, looking through her ECGs (heart tracing), it was noted that she might have also suffered a silent heart attack. A further blood test confirmed that she definitely did have a heart attack whilst in the hospital. She was hardly passing any urine because of her poor kidney function. She had antibiotics and intravenous fluids running to treat her illness. Looking at her co-morbidities, I felt that she is such a frail old lady with hardly any quality of life. I made the decision that she should NOT BE RESUSCITATED (DNAR) in the even of a cardiopulmonary arrest, but we should, however, continue to treat whatever we can.

Later in the morning, she became even more unwell. She started to breathe really hard and her oxygen saturations deteriorated. I wondered whether she was overloaded with fluids or her chest infection has worsened. I made the decision to perform another chest x-ray and repeated a couple more blood test. At that time, I was assisted by a specialist nurse and a few other staff nurses.

The moment they heard that I was going to get another chest x-ray, they looked very puzzled. They questioned me about it. They said, "But she has a DNAR status. Why are we still doing chest x-rays and repeating blood tests?"

I felt abit frustrated with that question. From my humble opinion, although she is no longer for resuscitation, there is still an opportunity to reverse anything that could potentially be reversible. As far as I am aware, a DNAR means do not attempt to restart the heart when it stops beating, and NOT withdraw any treatment. If we were not going to do anything about her increasing respiratory distress, then why even asked me to review her?

I mean, let's face it, if she did have fluid overload, this is treatable with diuretis etc. And she only had 3 days worth of antibiotics, so if her chest infection is worsening, we could try to add a few more antibiotics to see if it will help. I mean, we should at least try a minimum of 7 days of antibiotics before we could say, "oh right, looks like she's not going to improve...we have tried what we could."

I don't know. I felt that my decision was not supported by my fellow team members. Deep inside of me, I still did not want to give up on that poor old lady. I know she is demented, she does not have a clue on what is happening, but I believe that if there is a chance to treat something, we should still try before giving up on a life....rather than let her die uncomfortably.

To treat or not to treat? DNAR or not, I personally feel that she should try our best, and only give up, if there is evidence that she has not responded at all.
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