DIL DNR whats really going on

what ive learnt in medicine is at some point we all have to let it go.

the first time i knew what DIL DNR meant i was overcome with a tremendous helplessness.
to me DIL DNR simply means theres nothing to be done and all we can do is stand and watch.

my first encounter with DIL DNR was a jaundiced patient with hepatitis b and massive distended abdomen. the prognostic score was childs C. it was the first time i found out that someone could be scored as C. she was there in the ward, in one corner tucked away for 1 week. everyday i passed over her and i noticed that the tinge of yellow got yellower. her condition deteriorated as each day passes. foams would appear from her mouth, it got more in quantity and frequency. she was already in a coma when i met her. hepatic encephalopathy i was told. it meant there were too much ammonia inside her brain making her lose conciousness.

DIL means death in line. it meant the condition was a life threatening one. it also meant that there was no cure nor recovery. the condition would be a downhill one. what attempts we could do was to prolong time. perhaps buy some time so that family members could gather and bid goodbye. whenever DIL was issued, i would soon realise that there will be many visitors coming in. prayers were done often. sometimes hopeful visitors would stop me and ask if there was a slight chance of recovery. i could sense their desperation and a tiny twinge of hope from their eyes as if willing me to say yes. i wouldve given false promises that land me in trouble if i has given any signs of compromise to their pleads. initially i would shy away and inform them that its best to consult the specialist. few days would pass and the same question would be asked to me. by then ive observed enough words specialists would use to reply. my statements were usually im afraid the condition doesnt look good. or i would explain to them what are we treating for and show them tests that things are indeed getting worse. it was tempting for me to say eventually they will die but its too crude. its almost inhumane to utter such atrocities. most of the time the family members wouldve understood. i can see the sadness in their eyes. the limp nodding of the head, the silent sigh and sometimes tiny drops of tears forming in their eyes. usually i would silently exit myself or a gentle pat on their shoulder.
i soon also realise the reason why they keep asking me the same question. they needed confirmation. they believed that by reasoning it out they could accept the outcome. sometimes i could sense their frustrations. the same frustrations that i felt when medicine has nothing more to offer. i would suggest ways of easing the suffering of their love ones. gentle massaging, hourly turning or prayers. anything to make sure their love ones doesnt feel alone in their passage towards the end. im not sure how all of this helped them to face the fact that their loved one was indeed dying. but i feel no one should face death alone. i wouldnt want to be alone with death.

DNR meant do not resuscitate. no cpr. no medications to revive patients.
the reason why DNR is issued was if the doctor felt cpr would bring more harm than good. why prolong the suffering? why not let the patient die in peace. unnecessary intubation and admission to icu was not going to help. if anyone did aggressive resuscitation despite DNR issued its going to be a medicolegal issue. the fact is not many survive after cpr. mostly died after a few rounds of cpr. the ones who made it were a symbol of miracle. ive met a few who developed brain damage after cpr. it was the most cruelest outcome. i saw how much suffering the event caused. an incapacitated human being, bed bound,developing tons of complications like bed sores, pneumonia,etc. it was like a start of a very painful ending.
DNR was hard in the sense that families often feel that we doctors refuse to do anything to save their loved ones. its hard on the clinician where in their whole life theyre trained to save lives. good communication will help ease the shock to the family receiving the news but still emotions are hard to control.

i wouldnt lie that i didnt tell myself that i explained to myself that DIL DNR was the best for the patient. to be able to die peacefully and with dignity is a basic human right. these moments highlight the fine line that doctors are not god. the limitations of medicine is fairly clear here. whenever the nurse inform me that the bp pulse or oxygen saturation is dropping in a DIL DNR patient, i still go and attend. there are no crash cart following me. no cpr performed. i went and observe my patient, quietly asking god to ease their suffering and give them a smooth transition from the living realm to the realm of death.
as the breathing ceases, the heart slows down and the eyes becomes fixed, i pronounce the time of death and update the family. one live has just ended. soon the mortuary will come and transport the body away from the ward. i stamp the papers and the death reporting. case closed.