[ExI] Signing your death warrant

[Rafal Smigrodzki]

Recently the hospital administration, in their wisdom, decreed that I have
to ask each and every patient I admit about his preferences regarding
resuscitation. Previously I did not do it, the default being full
resuscitation, that is doctors making all efforts to restart the patient's
heart and breathing should they stop but be potentially recoverable. Now I
have been asking the same questions multiple times a day and I am shocked
about the answers I hear.

Let's not discuss much those who say they do want to be resuscitated -
aside from mentioning that sometimes people are distressed by having the
question posed to them. Do they wonder if I am, well, hesitant to do
everything to help them? That I am eager to let them drop dead, if they
would give me an excuse? From the way many react I gather they get
suspicious and I immediately reassure them that I only ask the question
because "they make me do it".

But very often, when I ask "If your heart stopped, would you like the
doctors to help you or not?" they say "No, do not resuscitate, I have the
papers, living will, advanced life directives and whatnot", as if they knew
what we are talking about. If I stopped questioning right there, the order
DNR would be entered on chart. But I always follow up with "So let me make
sure we understand each other - if your heart stopped, and we could get it
restarted, with an electric shock and medications, and get you back to your
normal life, you want the doctors to stand around while you are dying and
do nothing? Are you sure?". Nine times out of ten the patient, even the
ones with all the papers filled out and signed and validated by lawyers,
will say "Well, if you can get me back to normal, help me, I don't want to
die, I just don't want to be hooked to a machine and never get off it".

There is a common misunderstanding among patients that when they sign their
DNR papers they just make sure that their lives would not end in a futile
and painful ICU stay, on life support, to be eventually terminated without
ever going back to a life worth living. But in fact, DNR means much more -
it means no efforts will be made to help them even if their chance of
recovery is high. I once had a patient who coded almost ten times, and was
resuscitated successfully, usually within less than a minute by one or two
defibrillator shots, and walked home none the worse for wear, with a new
pacemaker. This situation, a sudden cardiac arrest in the hospital on
telemetry (heart monitoring) is completely different from an unmonitored
cardiac arrest, or arrest in the course of progressive and irreversible
disease. The former has a very good prognosis, as in my patient with ten
lives. The latter is what DNR should be about - situations when efforts are
often futile and result in wrongful life - short, painful, meaningless
survival of the body while the mind is already too far gone, even if not
strictly speaking brain dead.

Unfortunately the DNR papers don't really make a distinction between them,
or the distinction is lost on many patients when they talk to their
lawyers. How many hundreds of thousands of Americans are admitted to the
hospital every day? How many tens of thousands have DNR orders they never
really meant to authorize? What if your doctor just takes your "No, no,
just let me go" at face value, and marks you for death you don't really
want?

My guess is it happens all the time but nobody pays attention because those
who are harmed are all dead and speechless, and the paperwork is ok.

If a doctor, a lawyer or another huckster asks you if you want to have DNR
orders be sure you really know what the story is about. You don't want to
sign your own death warrant accidentally, do you?

Rafal
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