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).

Rage, rage against the dying of the light: The Fighter and the Pyrrhic Victory

It's only been two days since my last post on prognosis and end-of-life care in the ICU, and I'm anxious to blog about today's NEJM article on low tidal volume in the operating room on the Medical Evidence Blog, but the happenings around me already today mandate another post about realistic prognostication and it's effective communication.

When I make an assessment of a patient in the ICU, my list of summary conditions and conclusions often looks something like this:




ASSESSMENT:

1. Advanced age
2. Poor Functional Status
3. Malnutrition/Cachexia
4. Swallowing dysfunction
5. S/P fall and hip fracture
6. Aspiration pneumonia
7. Congestive Heart Failure
8. Respiratory failure
9. Renal failure
10. Poor Prognosis for both survival and return to independent livinng
    

This is not the norm.  The norm is to methodically list all of the acute and chronic medicalized and pathophysiologically interesting diagnoses.  In that vein, obvious things that can't be traced to a medically interesting and well delineated disease cascade are left out (such as advanced age and poor functional status.)