There is no room for used-car sales­man tac­tics on the part of med­ical pro­fes­sion­als when it comes to DNR matters. 

A recent land­mark rul­ing by the Supreme Court of Canada rejected a doctor’s uni­lat­eral right to deny life-sustaining med­ical treat­ment to a patient over the family’s objec­tions. Atten­tion needs to turn now to another life and death sit­u­a­tion that is often bewil­der­ing and some­times fraught with abuse: the do-not-resuscitate (DNR) deci­sion when made by a fam­ily on behalf of a loved one.

Physi­cians will often seek a DNR con­sent from a fam­ily mem­ber when an older patient is brought into the hos­pi­tal. Their approach can be overly aggres­sive. I expe­ri­enced this sev­eral years ago when my mother was hos­pi­tal­ized with a seri­ous infec­tion. Her fam­ily doc­tor asked us to agree to a DNR order soon after admis­sion. Know­ing my mother’s wishes, we declined to give our con­sent. Her doc­tor angrily announced he could over­ride the family’s deci­sion. A few days later, when my mother was pre­sent­ing with symp­toms of fever and delir­ium because of the effects of the infec­tion on her brain, the doc­tor sought the con­sent from her. My mother was in no posi­tion to know what was being asked of her. Aston­ish­ingly, her doc­tor pro­nounced him­self sat­is­fied with her response and signed the order. When we expressed our objec­tions to the hospital’s admin­is­tra­tion, we were told the only way the order could be over­turned was by obtain­ing a court injunc­tion. We were told to get a lawyer. It was Christ­mas day, 2008.

Some years later, dur­ing another hos­pi­tal­iza­tion, sim­i­lar pres­sure was exerted. A young res­i­dent who had not seen my mother and did not know any­thing about her prog­no­sis nev­er­the­less was deter­mined to obtain a DNR con­sent from us just after she had been flown in by air ambu­lance. He claimed sta­tis­tics showed that vir­tu­ally no one over the age of 80 sur­vives a car­diac arrest. We declined to con­sent. Less than two weeks later, my mother arrested in the ICU. For­tu­nately, she was revived. She was 89 at the time.

In the world of health­care, where decep­tion and efforts to cover up what actu­ally hap­pens are all too com­mon, a new scam has emerged. It is called the “slow code” and it hap­pens when a fam­ily or patient has not con­sented to a DNR order but the code team thinks the arrested patient would be bet­ter off if he or she were not revived. So the hos­pi­tal goes through the motions of resus­ci­ta­tion, but as slowly as pos­si­ble. In a sit­u­a­tion where the chance of recov­ery is mea­sured in sec­onds, the out­come of the slow code is pre-determined. No record is ever made of the deci­sion to delib­er­ately delay revival. It does not appear any­where on the chart. But clin­i­cians admit it does happen.

There is never a do-over when a DNR con­sent is put into force. Three years after her arrest and revival, my mother is still liv­ing with her fam­ily. Her recov­ery was made more costly and dif­fi­cult by that sen­tinel event and by a suc­ces­sion of other hos­pi­tal mishaps and fail­ures. But she remains curi­ous about the world around her, engages in con­ver­sa­tions and enjoys her music and her gar­den. Fam­ily meals are her favorite time of day. Our mother’s is still a life that gives and receives joy. How would we feel today if we had deprived her, and our­selves, of that by acced­ing to the hospital’s urgings?

Life and death choices can never be left to whim, nor should they be made dur­ing emo­tion­ally charged cir­cum­stances or in peri­ods of utter exhaus­tion. There is no room for used-car sales­man tac­tics on the part of med­ical pro­fes­sion­als when it comes to DNR deci­sions. In sit­u­a­tions where a fam­ily mem­ber has not pro­vided advance direc­tives as to their wishes, there needs to be a com­mon pro­to­col, set out in law, estab­lish­ing what steps hos­pi­tals are required to take in seek­ing and obtain­ing a DNR order. It should, at a min­i­mum, be based on informed con­sent about the con­di­tion of the patient and prog­no­sis for recov­ery. It should involve two meet­ings with a senior physi­cian, not some­one just learn­ing their craft. In addi­tion, steps in the resus­ci­ta­tion process should be spelled out clearly. Some fam­i­lies might agree to any effort short of chest com­pres­sions, where there could be a risk of injury. The full range of med­ical options need to be dis­closed. It goes with­out say­ing that aggres­sive atti­tudes and per­sonal agen­das on the part of med­ical per­son­nel should be left at the door and their inter­ac­tions with fam­i­lies should always be sen­si­tive and compassionate.

These are a few ideas to start a pub­lic con­ver­sa­tion that should begin imme­di­ately as more and more patients and fam­i­lies will face life and death deci­sions in the hos­pi­tal set­ting. Patient Pro­tec­tion Canada is work­ing on devel­op­ing a core set of account­abil­ity prin­ci­ples gov­ern­ing the rela­tion­ship between the health­care sys­tem and the patient. The DNR decision-making process, and issues like “slow code,” will be addressed in these principles.

Pub­lished in The Huff­in­g­ton Post, Octo­ber 25, 2013