NDR Deci­sions Need to be Made a Whole Lot Safer, More Trans­par­ent and Less Emo­tion­al­ly Harm­ful  for Patients and Fam­i­lies. 

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