D.N.I., D.N.R.

Do not intubate, Do not resuscitate. Usually, we give relatives of critically ill patients a choice, whether to resuscitate the critically ill patient or not. We explain the patient's case thoroughly, and when we believe that there is no more hope for the patient to get well, we inform the relatives of this option. People have different reasons for not wanting to resuscitate their relatives. Most people say that they do not want their loved ones to experience any more pain and suffering, especially if the illness has been chronic. Their loved one has already gone through enough. I believe others base their decision on their finances... though they do no admit it. I believe most of them really do care for their relatives and they want us to keep trying even when all hope is lost--- they just couldn't afford it. But I get the feeling that some are relieved when we bring up this option--- relieved that their bank accounts could finally take a breather. Whether or not they truly cared for their patient is beyond my perception. I understand how someone could choose not to resuscitate a person they loved deeply when resuscitation could offer nothing more than to prolong the inevitable, and simply result to broken ribs in the process. When all is lost, the best option at times is to let go.

But what if resuscitation can clearly save a patient's life? I understand patients who refuse to give consent--- after all, intubation seems to be a very uncomfortable, even painful procedure. If I was conscious, I doubt if I would give consent myself. But when the patient cannot decide on his own, whether conscious or unconscious, I can't understand how their guardians choose not to resuscitate even when we explain the benefits to them. Why bring these patients to the hospital when they refuse to allow us to perform the appropriate management? At times I'm tempted not to follow protocol and just pretend that the patient has no guardians or relatives so that I could do whatever I must do to try and save a person's life. I couldn't understand the relatives of this one patient who could still speak, who could still walk, who is still capable of emotions--- and yet his relatives ask us outright if they could already sign the form that says that we shouldn't resuscitate the patient in the event that he goes into arrest. I guess I'll never understand why some people behave the way they do.

Last week, another patient came in with difficulty of breathing. Breast Cancer Stage IV, with pleural effusion. Thoracentesis and closed tube thoracostomy done several times. The disease was no longer curable, patient was discharged from where I used to work a week prior, and was told to just let the patient spend the last few days of her life at home with her loved ones. Right off the bat, the patient said she did not want to be intubated. She did not want to have needles injected either, and inserting a chest tube was definitely out of the question. She was quite delirious, screaming and gasping for breath, yet asking for soup, which would definitely quickly ended her misery if her request was heeded. We turned to the relatives, and they said the same thing. They did not want to have any resuscitative measures done, because the patient did not want to. I wouldn't call it ignorance because we kept on explaining everything to them in simple, clear layman's terms. It would be harsh to chalk one up for stupidity, but I could think of any appropriate term. Maybe stubbornness. Maybe weariness. Maybe surrender. There she was, screaming and gasping for breath, and we couldn't do anything--- except watch her slowly die. A few hours later, she finally succumbed to pulmonary arrest---- just when her relatives decided to just bring her home. Maybe we should've just let her have her soup--- at least she would've died with some sense of satisfaction, her last request granted.

I've always thought that I was already numb to the idea of death, having witnessed a number of deaths each day that I am working at the hospital. One patient died, no big deal, just move on to the next. But on that moment, I couldn't help but feel sad. I knew that our hands were tied and it wasn't our fault, but I couldn't help but feel guilty. Maybe we should've tried convincing them more, maybe we should have tried harder. Maybe we should've thrown protocol aside and just pretended that we did not need their consent. Foregoing consent may be deemed unethical--- ignoring the patient's rights, physicians playing God, imposing on others what they believe is best... but for me, the sin of omission seems just as unethical... even more so.

But what do I know? I'm just a hospital employee carrying out orders, following protocol, in a line of work where having a conscience is a sign of weakness. With all the pain, death, and suffering we face each day in our working environment, letting emotions overwhelm you could only lead you to the brink of your own sanity.