Question
13: When should Do-Not-Resuscitate orders be
written for you?
A Do-Not-Resuscitate order is a doctor's instruction written
into your medical chart (often a loose-leaf notebook) which
tells the nurses that if you begin to die, no
attempt will be made to interrupt the process of dying.
Most hospitals and nursing homes have written policies of
always attempting to resuscitate patients when dying begins. Medical
institutions have automatic procedures in place, which
will be called immediately into action to provide cardio-pulmonary
resuscitation (CPR) —which
attempts to make your heart and lungs work again— and
other measures to restore vital functions.
The only way to avoid this automatic response is
to have an order written by your doctor in your chart stating that you do
not want to be resuscitated if and when you begin to die. This
is usually called the DNR order—for Do-Not-Resuscitate.
Until the 1980s patients and families were not asked about DNR orders. It
was a private (and sometimes secret) decision by the doctor. He
knew when further attempts to save the patient would be futile; and
he ordered the nurses not to call the resuscitation team —the
"crash cart"—if the patient's heart or lungs stopped functioning.
It was not uncommon in the past for a doctor to decide (without
consulting the patient or the family) to
create a secret Do-Not-Resuscitate order for the patient. This
was done by purple dots pasted on the patient's chart, special
marks on the door of the patient's room, a
code word or number—in pencil—on the patient's card in
the cardex at the desk (thus not a part of the patient's chart), or
a list on a blackboard at the nurses' station. All
of these secret signs were intended to communicate with the staff while
at the same time keeping the decision secret from
the patient and/or the family members. These
secret DNR signals were kept outside the official medical record so
they could easily be erased, removed, discarded, etc. —and
the fact of the decision not to resuscitate could easily be denied.
Such paternalism by the doctor was supposedly for the patient's
good. But
some studies have shown that the doctor's views of
who should be resuscitated were more often wrong than right when
compared to the views of the patients and their families.
122
YOUR LAST YEAR: CREATING YOUR ADVANCE DIRECTIVE FOR MEDICAL CARE
But since the 1980s, new laws require informed consent from
either the patient or the proxies for a DNR order. The
doctor is still the primary professional consultant for DNR orders, but
the basic decision must be made by you and/or your proxies. If
you do not want to make a DNR decision yourself, you
can assign this responsibility to your proxies, but
you should provide some guidelines in your 'living will'.