OLD does not mean: Ok to Let Die


Journals customarily publish letters to the editor responding to recent scientific articles, and much less often (if ever) do they allow comments on their humanities pieces.  Yet on par with other types of academic work, a good narrative can educate, stimulate discussion and spark controversy.  

In a recent Annals of Emergency Medicine, Dr. Leana Wen’s Change of Shift titled “Old” is a great humanities piece, honest and powerful.   However, the case as described is deeply concerning, compelling me to respond. 

A demented DNR/DNI patient presents to the ED in respiratory failure and is allowed to expire after a resident physician confirms the advanced directive and withholds non-invasive respiratory support on the request of the health care proxy.

The story is a true-to-life documentary of a thoughtful and caring clinician’s deference to advanced directives and family’s wishes. Readers might even celebrate this example of “death with dignity” in the
ED with family present and patient’s spirituality respected. 

I would agree, if not for the issue of autonomy. 

“Help… me… breathe…” the patient begs the resident upon arrival.  At that moment, it seemed clear that the patient chose to receive non-invasive ventilatory support until further clarification. Did his age, DNI status and reported dementia invalidate his apparently lucid demand?

The resident discontinues the BIPAP upon the request of an “adamant” niece.  A dialogue between the resident, her ED attending and the niece about efficacy, comfort, non-invasiveness and reversibility of
BIPAP was left entirely out of the narrative, hopefully to save print space and not because it did not occur. 

I must applaud this physician’s efforts to understand the patient’s life, medical history and spirituality; however I wish the patient’s most up-to-date directives were not ignored. 

A narrative such as this does more than tell a story; it implicitly teaches clinical norms and limits. I am concerned that the next generation of doctors will learn to simply allow a DNI paper and a health care proxy to overrule a human being pleading for a breath. 

To me, a situation this complex warrants a presentation of more complex decision-making process than the one described in “Old.” 

Some may say this is too much to ask of a narrative.  I would respond that narrative have a power to change hearts and minds; a power that comes with a responsibility to the reader.

Boris D. Veysman, M.D.
University of Medicine and Dentistry of New Jersey
Robert Wood Johnson Medical School, New Brunswick, NJ

Reference — Wen, L.S.  Change of Shift: Old.  Ann Emerg Med. 2011;58:305-306.

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  1. #1 by Simone Fitzgibbon - November 21st, 2012 at 15:36

    Thank you so much for your philosophy and perception. I have experienced two similar incidents in my family and am glad I was there to advocate for precious time for them.

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