by Constance Daley
American Reporter Correspondent
St.Simons Island, Ga.
August 19, 2003
ST. SIMONS ISLAND, Ga. -- Life is a game of chance but there are those out there who are trying to mark the cards.
A few years ago a new practice began that escaped my notice. Originally, when DNR was marked on a patient's chart it meant Do Not Resuscitate. And, I believe, no extraordinary measures would be taken to restore a patient's vital signs if they failed to function.
This action was not taken frivolously; a patient may already have been brought back from the jaws of death, hooked up to machines capable of carrying on life's functions, had the appearance of life but not the actuality. Once the machine was unhooked -- "pulling the plug" -- if the patient continued to thrive, routine care would proceed, but no "extraordinary" means would be employed.
The DNR instruction has been changed to DNAR, meaning Do Not Attempt Recuscitation. There's a fine line there but it's more acceptable. The original DNR carried the inference of choice and outcome. "Do not" is a command and in this case says this patient is as good as dead.
"Do Not Attempt Resuscitation," on the other hand, infers the patient is at peace, as pain-free as possible and waiting for the inevitable without the encumbrances attending "extraordinary" measures.
The slight difference was hardly noticed. It could be argued only as a matter of semantics; the order did not change at the treatment level one iota.
However, I read about that distinction prefacing a discussion on "priority rationing." Now, this "rationing" makes a difference to me, especially since I'm only on one end of giving and receiving. I feel like a man when the "women and children first" order is given.
What exactly is priority rationing? I'll refer to David C. Hadorn, M.D. M.A., who, in a letter to the New England Journal of Medicine, 1999, wrote:
"Part of the problem here stems from serious ambiguities that continue to exist in our use of the word 'rationing.' I would like to recommend that the most useful definition for present purposes of health policy analysis is this: 'rationing is the societal toleration of inequitable barriers (especially financial) to access to health services which have been duly acknowledged [viz., through sanctioned appropriate- or necessary-care guidelines] to provide significant benefit to patients with specified conditions."
From what I get from that society would be expected to accept inequitable access to health care services. Dr. Hadorn wrote parenthetically "especially financial." My thoughts don't go in that direction as I write; my thoughts are on the running theme in professional articles on this subject "Priority would be given to the patient with the most likely benefit."
That suggests to me a point system is in play. Suppose two persons present themselves for knee replacement and one is in severe pain, the other moderate; one is over 70 and the other is 55; one is an active man, the other is a stay-at-home woman.
Because surgery must be scheduled and time allotted, and because the surgeon must check his calendar against any scheduled conflict, the operating room could be scheduled for the patient with the most likely benefit. It would seem "first come, first served" would be more fair because who's to say which of the patients has more need?
While I'm fully aware that "a little knowledge is a dangerous thing," I must admit here I have very little knowledge on the subject, but I have perused a number of studies and this appears to be the trend. I'd like to know exactly how the system works before I'm on a gurney in hospital hall waiting for my point system to be tallied.
I'm picturing Miss America, or figure skaters and gymnasts, who have given their all and now wait for judges to determine which one makes it. "The decision of the judges is final." Oh, that sounds ominous.
The idea is to achieve maximum health gain with the funds available. There's something wrong with that sentence. One should not have anything to do with the other but I recognize my head is in the sand. The inevitable is about to happen. I remember the line (perhaps biblical): "What you fear the most is thrust upon you."
So, I see myself on that gurney outside the hospital room door. I turn and see a woman on the gurney next to me also waiting for that room. The judges are checking a list. I think I'll score rather highly. I stopped smoking, I take vitamins, I sort of exercise, my weight is on target, I've really taken care of myself. Yes, I think. I'll be okay.
I can see the woman still smokes, she's looking around furtively for anyone who might break hospital rules and give her a drag. No, they'll have to get her in shape before they put her under anesthesia.
Well, I was wrong. Even though this was all in my imagination, it could happen. I see them taking her in and leaving me to wonder why. Then I see blood. She has a slight scalp wound (probably bumped it on the cupboard) and all the judging is over. Blood takes precedence over everything else.
Priority rationing extends to medication as well. Some drugs cost as much as $150 a day or more. If the decision to prescribe it for an older person (say, me) or a five year old, then I would balk. Who is to place value on which life? The child could leave the hospital and run into the street to be hit by a car while I have long since given up running into the street. It's just an example illustrating nobody has the right to judge when it's life or death.
If, however, the older person (say, me, again) is one of two people desperately needing a rare medication and the other person is my grandchild or a beloved little person I know, then it would be my call, I believe, based on the thoughts in my mind: Things I've done, things I'm too old to do; things he has yet to do all enter into it. I wouldn't even pause before putting my name on the dotted line. I probably would do it for a stranger across the world somewhere.
But, I will make that judgment, if you don't mind, not some pencil-pushing financial advisor with numbers to crunch, slots to fill and quotas to make. Not over my dead body.