The famous saying tells us that there are two things we can’t avoid, death and taxes. Media reports will quickly relieve us of the latter belief as we see how many successfully avoid paying taxes; the former is something we must face.
Yes, some seek the wonders of cryonics in the hope their illness will be cured in the future and they will come back to life. The medical community is not optimistic about this prospect.
But for those who are not seeking such extraordinary interventions, there is the legal constraint of a DNR (do not resuscitate) and an advance care directive for anyone who wishes to avoid unnecessary, possibly painful medical interventions when death is inevitable. The purpose is restraint in medical procedures, but not everyone will have their wishes met.
In some instances, the concern that a patient’s wishes will not be adhered to has led to their having “DO NOT RESUSCITATE” tattooed onto their chest. But does that work?
The laws regulating healthcare and DNR vary by state, and a physician must sign a DNR. How do you do that with a tattoo? The body paint is supposed to be an extra incentive for medical staff to read the patient’s chart and see if they did sign the document. It’s similar to surgeons marking a limb scheduled for an operation. Too many people have had the wrong limbs amputated, and that led to this extra measure of care.
Until a national DNR becomes reality, healthcare professional should continue to help people become aware of the need for and best way to communicate end of life wishes. The real question comes under “risk management,” which means lawsuits and ethical obligations to most consumers. Anyone wishing a DNR form for their state can download one.
I am not without some experience in meeting people who have had relatives die and who had DNRs that were not honored. Helplessly, one woman had to watch as her father was intubated, his body became a grotesque form of his former self, and he lay dying for days.
And she felt guilty because there was nothing she could do. It was like the famous “Terms of Endearment” scene where Shirley MacLaine screams for her daughter’s pain meds and is ignored.
My patient was angry because as much as she pleaded with the medical personnel and pointed to his DNR, she received no attention; the staff kept doing what they had been doing. What might the problem be, you ask? How about legal concerns of being sued for not intervening and, as a result, disregarding the DNR? It doesn’t sound like a robust legal document, does it? Does the question now remain how we remedy this?
But the DNR has also been used unlawfully in some instances of persons with disabilities. A more insidious practice has also been brought to light in which some doctors have been placing unlawful DNR orders on the records of individuals with learning disabilities without prior consultation with the person’s family or carers.
In one study, 65% of the respondents who were disabled feared they would not receive needed treatment if they became seriously ill. It was unclear if they believed DNRs would be the cause or if they had DNRs in their files.
The patient’s wishes are, in some instances, a function of a physician’s experience, training, and life experience. Ability to participate in goals of care discussion is an important skill to be honed by physicians in both inpatient and outpatient setting for ensuring appropriate management of patients in accordance with their value. The lack of training in such discussion can lead to a lack of guidance for the patients in settings of terminal illness and inappropriate use of healthcare resources.
Is “value” something to be considered? Are they writing about how a patient values their life or how the staff values the patient’s life? Two very different perspectives and the tendency can be to be too proactive or too willing to decline to follow the directive. The will of the patient should prevail, but does it? And, if not, what might the consequences be for healthcare professionals?
The intent of writing DNRs was to provide a sense of control of our bodies over medical interventions according to the patient’s wishes. It can provide a degree of comfort in a difficult situation. When we see a total lack of regard for the patient’s wishes where the personnel assumes a godlike attitude, healthcare facilities assume a mental patina of fear.
