Friday, July 11, 2014

Should DNR be the Default Resuscitation Order After a Certain Age? The Case of Arnold Relman

"Oh lente, lente, currite noctis equi."  - Christopher Marlowe, The Damnation of Doctor Faustus

In at poignant and pithy piece in the New York Review of Books this year, the late Arnold Relman, former editor of the NEJM, described his experience breaking his neck and having cardiac arrest three times in the trauma resuscitation bay.  Because Relman was a visionary and outspoken pioneer in the movement to recognize and reduce medical waste and runaway spending (according to his recent obituary in the NYT) I thought it would be timely rather than disrespectful to evaluate the last year of his life after his accident as a case study on the utility of resuscitation in advanced age (I will not here attempt to define advanced age - only to posit that it exists at some cutoff that could be defined statically or dynamically).

Relman was 90 years old last year when he suffered the injury that is the subject of his writing.  With the limited information available from his own accounting, I can determine that he most likely had the classic triad of poor prognosis in critical illness:  advanced age, poor functional status (he could not climb stairs, had an unsteady gait, walked with a cane, and had a chair lift installed in his home) and several medical comorbidities (atrial fibrillation, aortic stenosis, polymyalgia rheumatica).  When an elderly person (especially one with poor functional status) falls during routine activities of daily living (especially if bone(s) are broken) it is often a harbinger of the end of that person's life, as experience dictates time and again.  The young and healthy do not fall during activities of daily living, and when they do, they do not break bones.  Thus a fall in an elderly person often marks a turning point in functional status (the inability to maintain body position).  It also signals frailty as evidenced by a fracture.  Moreover, it is often a serious setback in terms of those very two things because the injury, healing, and convalescence diminish functional status and increase frailty further.  I am not here talking about what ought to be but rather what is.  In this discussion, a judgment about reality is not my concern - my concern is rather in describing the reality.

Relman fell down the stairs and broke his neck.  During the resuscitation that followed in the trauma bay, he lost his airway and received an emergency tracheostomy, during which he experienced several cardiac arrests from which he was successfully resuscitated.  He then underwent emergency surgery for the cervical fractures, spent 11 days in the ICU, had a repeat tracheostomy and a feeding tube placed.  He was then discharged to an LTAC where he spent a month before returning home.  It is worth reading his piece entitled On Breaking One's Neck to learn from his experiences and observations during his injury, illness and recovery.  His medical bills, paid for by his Harvard faculty insurance plan and Medicare totaled about $400,000.  Relman was intellectually active after his recovery and continued to write, but alas he died just short of one year after his injury on his 91st birthday - June 17th, 2014.  (Much commentary could be made about this apparent coincidence - and I'm not sure it is a coincidence.)

Relman's case is, unfortunately, an emblematic case study of falls, injuries and cardiac arrests in the very elderly.  We could debate ad nauseum about whether the 10 or so months of relatively unencumbered life Relman got from the $400K that the healthcare system spent on him during that time was worth it - and that debate is a worthy one to have.  Here I merely wish to emphasize the harsh reality - the triad of poor prognosis in critical illness is intractable, and even if a person does recover after a severe illness in the context of advanced age and poor functional status and multiple comorbidities, their time is limited.  The components of this triad are essentially inescapable - aging gets worse not better, poor functional status continues on its inexorable decline, and co-morbidities increase rather than diminish in spite of all the best well-intentioned efforts.  It is worth noting also that Relman, at age 90, had all the statistical hallmarks of someone who would do well against others with the same conditions - a meaningful life, high socioeconomic status, an engagement with life, a robust support system, active collaboration in his recovery and rehabilitation, a sense of control and dogged perseverance.  Yet even with the deck stacked in his favor, he too succumbed not long after his apparent recovery.

It is worth considering then, assuming we are willing to engage the topic of utility in healthcare and accept that resources are not unlimited, whether at some age it would be reasonable for Do Not Resuscitate (DNR) to be the default order for resuscitation.  But to be reasonable in this consideration, I would suggest that we not approach the question ex post, but rather ex ante with a veil of ignorance - as though we had to plan for ourselves how to spend limited dollars over our lifespans - not just on healthcare, but on everything.  Perhaps Relman or others like him would have been better off spending that $400,000 on a vacation to some far off land earlier in life than on a massive resuscitation from which he would die a year later at the end of life.  It's a worthy discussion to have, for each person to consider for himself or herself.

Meanwhile, Relman's case is instructive as regards to providing prognostic information to patients and their surrogates in the face of the poor prognosis triad and a life-threatening illness.  (This recent article in Critical Care Medicine provides data suggesting that critical care practitioners implicitly recognize the implications herein discussed.)  Even if he or she survives this bout of illness, time is running out and another bout is right around the corner.


  1. And has anyone considered whether Arnold Relman, with his poor functional status and inability to climb stairs should have been on anticoagulation for atrial fibrillation at the time of his accident?

  2. Gerald Larue, founder of the Hemlock Society and early advocate of the death with dignity movement, just died, at the age of 98: Gerald Larue Dies at 98 Remarkably, the NYT obituary says that his son considered putting him on the ventilator, after his stroke. This is absurd, because: 1.) this man founded the Hemlock society; 2.) he was 98 years old and just had a stroke! The power of denial cannot be underestimated.