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Neither system is perfect

Liz DzengLiz Dzeng

A profound experience for me during medical residency training occurred when I was caring for a 96-year-old woman with terminal metastatic cancer in the ICU.  During a protracted conversation where my colleague struggled to obtain a “Do Not Resuscitate” (DNR) order from the patient’s husband who had dementia, she had a cardiac arrest. Since she was still full code, I had to resuscitate her. I felt a great sense of ethical and moral wrong while performing rib breaking chest compressions and shocking her heart back into a “viable” rhythm. Experiences such as these have inspired me to pursue research comparing DNR decision-making practices between the United States and United Kingdom.

This window into normative practices in the UK has shown me alternative models of compassionate care at the end of life. UK physicians frequently invoked the phrase in “best interest of the patient,” as a reason why particular decisions had been made. My colleagues in the UK were surprised when I told them that I had never heard this phrase used in the US. Perhaps this linguistic difference reflects the fundamental differences between our system’s differing mentalities. American physicians tend to become preoccupied with technologically driven priorities such that we sometimes forget that the goal of medicine should be to keep someone healthy, and not just alive.

I remember hearing a British registrar (equivalent of a US resident) matter-of-factly saying that when a terminal patient arrives near death in the middle of the night, they are all likely thinking about what can be done to scale back treatment to allow a peaceful death. I found this a welcomed contrast to the typical mentality during my training, where the goal was to keep your patients alive until rounds. While conversations of scaling back would sometimes occur during attending rounds, I think residents often felt that a failure to keep a patient alive overnight through any means possible was an intellectual failure.

The most fundamental contrast between the US and the UK is that in the UK, the ultimate decision regarding code status lies with the physician. Not only does the legal decision making capacity lie with the physician, but the UK General Medical Council also stipulates that DNR decisions should not be disclosed if it would be “burdensome and of little or no value.” My shock over hearing this was echoed in their disbelief that American patients and families could demand to be full code. Particularly illustrative was one physician’s question of how US DNR practices were any more logical than allowing a patient to demand and receive an unnecessary appendectomy.

Neither system is perfect. Recent controversy in the UK’s Liverpool Care Pathway over the lack of physician disclosure and patient autonomy regarding withdraw of care in the dying, reflects a burgeoning demand for greater control in personal health care decisions. The US and UK’s differing prioritizations of autonomy and non-maleficence (the principle of first doing no harm) are reflections of our two societies’ histories and sociopolitical priorities. The British model would never work in the US given the United States’ emphasis on individual freedoms and choice, but there are likely some lessons that we can learn from the UK. In turn, the US serves as a cautionary tale for the UK as their society begins to demand more choice and autonomy in their own health care decisions.

Elizabeth Dzeng, MD '09, MPH '07

 

Comments

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  • Dr. Michael L. Gordy

    Ornex, France 02/02/2012 03:05:59 AM

    It is reassuring to see that a Hopkins graduate is helping orient global health towards effective measures focusing on the rural poor. Harnessing technological innovation to something besides cost cutting for its own sake is a salutary objective.

  • James Henry Chapman

    United States 02/08/2012 07:44:21 PM

    Thank God, and I am not just using a figure of speech here, thank God for this technology and for the people using it to heal and reduce the suffering of people who live in the under-developed parts of the world. Whenever the destructive uses to which I see technology being continually put bring up the latent Luddite in me, I'll have to remember the work being done by such groups as this and the essential role technology plays in it.

  • Greg Rockefeller

    Los Angeles, CA 02/11/2012 01:24:05 AM

    I've known John for years and his focus on solving problems of this type gives me hope for solutions that far surpass those that we've normally seen crossing the funding requests. With any luck a consortium of funders will step up and backfill the obvious needs presented here.

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