On the other hand, there is now definitely a culture (measured by off-hand comments by residents, facial expressions assumed when discussing families who do not make the "correct" decisions, and the like) which promotes the DNR order. It is taken by some as the very goal of goal-of-care discussions. If a patient is very sick, has been so for a long time, and the prospects for recovery of functional status (meaning a significant quality of life) are minimal, we are pleased when a DNR/DNI order is obtained, and even more pleased when comfort care is decided upon.
But I also want to talk to the patients fully and frankly about what "significant quality of life" means. If the patient (or her family) wants to be kept on a ventilator indefinitely, even if there is no chance of life off the machine, that would be valid - because medical futility, like all medical decision-making, involves ethical assumptions which patients and families might not share; and because health-care costs and resultant rationing, so often in the back or front of our minds when discussing such issues, are not significantly affected by long-term ventilator support. (See this brief article in the New England Journal for a discussion of both these issues.)
My goal this rotation, when I admit patients overnight at Bellevue, is to include as part of the problem list the category Goals of Care and to discuss these with the patient. This won't happen for everybody, and maybe for nobody (it gets busy). But it's something to work towards.
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