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Should Natural Death Be a ‘‘Billable’’ ICD-9Code?

T he only certainty in life is death. Why is it thenthat we as physicians are still uncomfortablewhen faced with a naturally dying patient? Is it

our inherent fear of dying or our immersion in our‘‘death-defying culture’’ that forms our attitudes anddecisions? Our discomfort is highlighted even more inemergency medicine (EM), where resuscitation is themost important goal. Some providers consider theDNAR (do not attempt resuscitation) orders, as instruc-tions to be passive and ‘‘do nothing.’’ Would an ICD-9code for ‘‘allow natural death’’ make us active partici-pants in end-of-life care? The case of an elder gentleman,dying, presented the ‘‘dilemma’’ for discussion eventhough it was the most natural and expected event at theend of his life.

PORTFOLIO ENTRY

The arrival of an elder, 86-year-old male with a historyof emphysema, found on his kitchen floor with alteredmental status, was routine. We evaluated, stabilized,and admitted him to our neurology service for a newstroke.

A short while later, when summoned to his bedsidefor persistently low oxygen saturations, we notified hisfamily of the deterioration and discussed the plan toprovide ventilation support. They handed me an enve-lope with his living will. Frustrating discussions fol-lowed, since no one had discussed end-of-life (EOL)issues with the patient. His advance directive stated that‘‘if he had a terminal illness with less than a 3-monthsurvival per his physicians, then no life-prolongingmeasures were to be pursued.’’ The family looked tome for its interpretation. Is he terminally ill and whatwould he consider a life-prolonging measure: a ventila-tor, pressors, fluids?

I was ambivalent! The patient not only had a stroke,but also had hypoxia and dehydration, both reversibleconditions. How could I formulate a reasonable prog-nosis on a patient I barely knew? I would surely hastenhis death by withholding respiratory support. Takingthe easier ‘‘middle’’ road, we initiated noninvasive ven-tilation.

Soon, his sister approached me saying, ‘‘Doctor, weunderstand he is very ill and dying. This machine ismaking him restless and he seems to be in pain. Wedon’t want to see him suffer.’’ As the only physicianconsistently at his bedside, I was granted instant trustto address his EOL care, so I finally shifted my focus tothe dying process. With family consent, we discontinued

the bi-pap, consulted palliative care and a priest, turnedoff the noisy monitors, prescribed Ativan for agitation,and requested a room with privacy.

On turnover rounds, the team went past the gentle-man with a cursory, ‘‘admitted, DNAR, nothing to do’’report. When a stony faced, ‘‘no-nonsense’’ attendingphysician made a side remark of, ‘‘you have wastedway too much time on this already DNAR patient,’’ itreally struck me!

If we had been placing a difficult central line or arte-rial line for the same patient’s management, or runninga long ‘‘code,’’ would he have made the same com-ment? If the effort to make a natural death possible wasbeing billed like critical care for every 30 minutes ofinvolvement, would my efforts have been perceived as‘‘waste’’? Is the time spent to explore patients’ prefer-ences, a waste? I felt that actively caring for a naturallydying patient does not evoke the same feelings ofinvolvement in physicians, as does a resuscitation, eventhat of an obviously futile, asystolic patient.

REFLECTION

This case highlights a host of issues related to EOL:patient choice versus evidence-based medicine, DNARinterpretation, determining and communicating a prog-nosis, and our attitudes toward natural death, to namea few.

Mortality statistics reveal that more than 1.1 millionindividuals died in U.S. hospitals in the year 2004, morethan 45% of all deaths.1 Patients also use acute careservices in hospitals more frequently in the last6 months of life, and this may actually be associatedwith worse health care outcomes.2

At every stage of their care, most patients expecttheir clinicians to keep them informed and take accountof their preferences. This partnership approach is alsoreferred as shared, or informed decision-making, orevidence-based patient choice.3 We know, ‘‘evidencealone does not make decisions.’’4 Research suggeststhat if patients are better informed they actually chooseless aggressive forms of therapy.3 This highlightsthe voluntary nature of the process and the possibilityof deciding not to undergo any treatment.3 Hollowayand Quill5 state, ‘‘Good quality deaths embody bothinformed decisions and optimal symptom control,’’which supports preference-based as opposed to evi-dence-based aggressive EOL care. Physicians may per-ceive this process to be time-consuming, and thereforeoften fail to explore their patients’ preferences.

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There are little data on how patients are dying andtheir preferences at EOL.5 Therefore, therapy inseverely ill patients may often be inconsistent with theirwishes. The rates and interpretations of ‘‘DNAR’’ varywidely across institutions and regions.5,6 Approximately75% of patients who present to hospital emergencydepartments do not have an advance directive.7 Evenwhen available, they may be difficult to interpret in thecontext of specific interventions. This illustrates theneed to communicate and clarify specifics of a DNARorder. Will our passive perception of advance directiveschange if we replace the ‘‘do nothing’’ connotation ofDNAR with an active phrase like ‘‘allow for naturaldeath’’ (used in many nursing homes)?

Research reveals most physicians avoid communicat-ing prognoses, especially when related to survival asopposed to functional outcomes. Even when they doprognosticate, they tend to overestimate survival, per-haps due to the desire to ‘‘not give up hope.’’ This falseoptimism is neatly captured by hospice nurse darkhumor: ‘‘Why are coffins nailed shut? So we can keepdoctors from giving more chemotherapy.’’8

Emergency physicians are the leaders in resuscita-tions. This satisfies us on many levels, including proce-dural competency and reimbursement. As the firstdoctor on scene, we carry this responsibility. We alsodeal with naturally dying patients almost daily, but havelimited clinical competency in this area. We are trainedto save lives rather than to manage death. Again, timeconstraints are blamed as a likely culprit for physicianreluctance to address EOL care, even though somestudies show that it only takes an average of 5.6 min-utes to discuss advance directives.9 Reimbursementmay not favor time spent communicating with families,but we gain the reward of emotional satisfaction, afamily’s appreciation, and pride as competent and effi-cient EOL care providers.

Palliative care has recently been recognized as asubspecialty of EM. Attending the first Education inPalliative and End-of-life Care (EPEC)-EM conferenceoffered to EM professionals proved to be an excellentinformative resource.10 We recently instituted mortalityrounds at our EM resident didactic conferences, with afocus on the dying process. The goal is to gain clinicalcompetence in EOL care and have an aggressive, early,goal-directed team approach to natural death. Is it notour duty to provide a ‘‘good-quality natural death’’ thesame way it is our obligation to provide good-qualityhealth care to our patients?doi:10.1111/j.1553-2712.2008.00063.x

Sangeeta Lamba, MD(lambasa@umdnj.edu)UMDNJ–University HospitalNew Jersey Medical SchoolNewark, NJ

References

1. Centers for Disease Control and Prevention. Mor-tality Tables 2004–Worktable 309. Deaths by placeof death, age, race, and sex: United States 2004.Available at: http://www.cdc.gov/nchs/data/dvs/MortFinal2004_Worktable309.pdf. Accessed Aug 16,2007.

2. Fisher ES, Wenneberg DE, Stukel TA, Gottleib DJ,Lucas FL, Pinder EL. The implications of regionalvariations in Medicare spending. Ann Intern Med.2003; 138(4):288–98.

3. O’Connor AM, Llewellyn-Thomas HA, Flood AB.Modifying unwarranted variations in health care:Shared decision making using patient decision aids.A review of the evidence base for shared decisionmaking. Health Aff (Millwood). 2004; (suppl Webexclusive):var63-var72. Available at: http://content.healthaffairs.org/cgi/reprint/hlthaff.var.63v1. AccessedFeb 7, 2008.

4. Haynes RB, Devereaux PJ, Guyatt GH. Physicians’and patients’ choices in evidence based practice.Brit Med J. 2002; 324:1350.

5. Holloway RG, Quill TE. Mortality as a measure ofquality: implications for palliative and end-of-lifecare. JAMA. 2007; 298(7):802–4.

6. Zingmond DS, Wengner NS. Regional and institu-tional variation in the initiation of early ‘do notresuscitate’ orders. Arch Int Med. 2005; 165(15):1705–12.

7. Ishihara KK, Wrenn K, Wright SW, Socha CM,Cross M. Advance directives in the emergencydepartment: too few, too late. Acad Emerg Med.1996; 3:50–3.

8. Christakis NA. The bad news first. New York Times.8 ⁄ 24 ⁄ 07

9. Tulsky JA, Fischer GS, Rose MR, Arnold RM. Open-ing the black box: how do physicians communicateabout advance directives? Ann Intern Med. 1998;129:441–9.

10. The EPEC Project. Education in Palliative andEnd-of-life Care. Available at: http://www.epec.net/EPEC/webpages/index.cfm. Accessed Aug 28, 2007.

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