RE: DNR in the Field

["Paul M. Wright, Jr." <pmwright@home.com>]

> >When discussing DNR issues, it should be asked not,
> >"what do YOU want us to do, but what would the PATIENT
> >want us to do?".  A signed legal document clearly
> >states that, and there you have your answer.
> >

Ted -

I think you have the question precisely correct.  But here in Arizona,
apparently unlike Ohio, while the law requires written assent to a DNR, the
revocation of such a DNR can be oral.

I had one patient with severe lung disease who was involved in several such
incidents.  When she was well, she would declare to everyone who would
listen that she did NOT want any resuscitative measures and she would sign
the necessary paperwork.  But when she was fighting to breathe and her CO2
had climbed to 115 (from her norm of 85-90), she would clearly indicate that
she wanted something done about it.  Her son, aware that she had signed the
paperwork but not aware that his mom had specifically requested intervention
in that episode, would usually threaten to have all the healthcare workers
involved in her care arrested
for assault.  We always just gave him the number of the local prosecutor and
by the time he got through their switchboard, we usually had Mom breathing
well enough to tell him off on our behalf.  After awhile, it just became an
amusing game we played, but it illustrates a scenario under which this kind
of conflict can occur.

There is also the problem of validating the document with which you are
presented.  People can and will forge paperwork, particularly where large
inheritances or significant guilt issues are at stake.

Based on Dr. Romig's post, I think the folks in Florida have the right idea.
Only when families co-sign the agreement and understand what they are
signing will the problem abate.

But to go one step further, we need to be proactive and prevent the EMS call
in the first place.  The situation in which a patient dies an expected death
at home (particularly under hospice care) should have a mechanism in place
that does not require a Code3 response by the local EMS agency. At least
here in Arizona, that mechanism does not currently exist in workable form
because all of these deaths are considered coroner's cases after the fact
and as workable code arrests until the facts are determined and known.
We've done a pretty good job of teaching people when to call 911 and maybe
now it's a matter of teaching people when NOT to call 911.

But as things stand, I think it both prudent and ethical to resolve any
doubtful situation in favor of attempting to resuscitate the patient.
Conversely, though, where there is no doubt as to the patient's wishes, our
role as an advocate for the patient will necessarily include observing those
wishes in spite of family opposition.

paul

Paul M. Wright, Jr.
Mesa, Az




















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