Treatment of ‘Do Not Resuscitate’ patients needs urgent review

 Hospitals should show more compassion, respect and care, and not abandon them.

From Dr AnZ

Dear health minister,

I write to you as a concerned medical professional and citizen of Malaysia.

Someone I knew died today. Someone whose time had come. Who am I to say that it should be delayed a second longer? Yes minister, he died in one of your hospitals.

Alone. Not because of a lack of family and friends. Not because of a lack of concerned relatives, but alone because of the healthcare system – and the care that he did not receive.

This is not an accusation. I have been part of this same healthcare system ever since I was a houseman. I have spent decades within the public healthcare system, witnessing from within, all its strengths and its failings.

I may have once taught the very same people who now denied a patient his rights.

My dear minister,

I know you are trying your best to revamp the entire healthcare system from problems affecting housemen to those affecting the GPs. I hate to do this, but I have to bring up an issue that is symptomatic of our current public healthcare system.

The issue that troubles me deeply, and which I bring up in the hopes of reform, is the treatment of patients labelled DNR (Do Not Resuscitate).

Many of us in the medical field and also many families of patients are increasingly worried about the DNR label. We all know what it means, our medical students understand the concept, and families of affected patients are told what it means.

Yet, there is a nagging feeling among medical professionals and laymen that the DNR label is increasingly misunderstood and often misapplied.

I am aware of all the health ministry’s directives and SOPs related to DNR.

I am not questioning their credibility; just concerned about the implementation of these directives within the busy hospital wards.

I am aware that a DNR order allows you to choose whether or not you want cardiopulmonary resuscitation (CPR ) in an emergency.

It is specific about CPR. It does not have instructions for other treatments, such as analgesics, other medication, or nutrition. The DNR order is a legally binding document, and if correctly implemented, it ensures that the end-of-life medical care aligns with the patients’ religious beliefs, needs and desires as closely as possible.

DNR is intended to mean that in the event of cardiac or respiratory arrest, no resuscitative efforts should be made.

It does not mean that the patient is to be neglected, denied care, or worse, left to die alone and unattended.

My dear minister,

The reality is that sometimes in your hospitals, DNR means minimal care of the patient and waiting for him to die.

In the last few days, I witnessed how my friend was bypassed for basic medical attention, his intravenous drip was allowed to run dry unnoticed, his bed sores were getting worse, his monitors were not calibrated well, and the alarm was constantly ringing to deaf ears.

His physical needs were unmet. He was left in discomfort. To me, he was dying, in silence, without dignity. When relatives questioned the lack of care, they were asked, “Why did you agree to the DNR? Why don’t you withdraw the DNR?”

I would like to believe this abandonment of a DNR patient was not intentional or due to malice.

Perhaps it is a lack of ability for some healthcare workers to understand the difference between “not resuscitating” and “not caring”.

Perhaps it is a lack of awareness of the comprehensive Malaysian guidelines to ensure that end-of-life care upholds patient dignity, comfort, and ethical standards.

Whatever it may be, in the weeks before his death, my friend was abandoned by those who vowed to do no harm.

A DNR patient is still a human being. He deserves comfort. He deserves attention. I am sorry to say that this is a failure not only of communication but also of policy and implementation.

If you have the time to talk to my friends’ family, you will realise that while they may not want their loved ones to be intubated, defibrillated, or sent to the ICU – they still want the pain controlled, the thirst quenched, the families near, and the final days filled with dignity. All of these were denied to my friend who died today.

So why did they not complain?

If there are so many of these families around, why have they not voiced their opinion? The answer is very obvious. People often do not voice their complaints after the death of a loved one in a hospital for several complex and deeply emotional reasons.

They are overwhelmed by grief, unsure if anything went wrong, or feel it will not change the outcome. Cultural beliefs, respect for healthcare workers, fear of being ignored or judged, and not knowing their rights also play a role.

Often, they just want peace and closure rather than clarity at the expense of conflict.

So, my dear minister, all is certainly not right within your realm. Perhaps it is time you took a leaf out of Caliph Harun al-Rashid’s playbook. He reigned from 786-809 CE during the Abbasid Caliphate.

He was famous for going out in disguise at night to walk among his people in Baghdad, listening to their concerns and observing their conditions firsthand. This allowed him to rule more justly and remain connected to his subjects. This connection with the community is seemingly lacking in your hospitals and it worries me.

There has to be a paradigm shift in our hospitals – one that reaffirms the humanity of every patient, especially those approaching death.

Primum non Nocere (first do no harm) also means we must not neglect. We must not abandon patients. We must not forget that silence and inaction in the face of suffering can also be a form of harm.

The measure of a healthcare system is not just in terms of how many lives we save. It is also measured by how we care for those seeking solace and dignity at the end of their lives.

I am not asking for clear protocols, because these exist. I am not demanding a national policy on palliative care or training in palliative care. These already exist.

However, I am asking for more compassion and better care for those who choose not to be resuscitated. Treat them with respect and care. Do not abandon them and leave them to die alone.

My friend was denied dignity in his death in one of your hospitals. Let this not happen again to anyone else.

Minister, I appeal to you to lead not just a policy change, but a moral one. I, along with many others in the medical profession and civil society, stand ready to support such a move. - FMT

Dr AnZ is an FMT reader.

The views expressed are those of the writer and do not necessarily reflect those of MMKtT.