I Am DNR

I am DNR – do not resuscitate.

Legally should I be hospitalized, I have signed paperwork stating there will be no CPR (cardiopulmonary resuscitation) including chest compressions, no medication to restore my blood pressure, and no artificial machine to breathe for me.  Also I have documents designating a power of attorney to speak for me if I am not able to speak for myself.  These were signed over a decade ago.

The latter part of my 34 years of practice has been in geriatrics, specializing in palliative and hospice care.  In fact, I will join many of my Baby Boom Generation in 2016 on Medicare, with the unfortunate knowledge of what to expect medically as I age.   

Digressing a moment, I have seen during my career the medical profession taken over by business.  Instead of doctors making patient care decisions, they are being made based on a financial bottom-line.  Health insurance and pharmaceutical companies along with hospitals have become clandestine profiteers, with proof of their executive deception seen in salaries, bonuses, and huge retirement benefits.

Some of their gains come at a cost to our patients with higher premiums, larger deductible, less drug coverage, and increased denial of care.  Even more difficult are complex rules and legal jargon doctors and patients face attempting to navigate through laws written by business lobbyists and special interest attorneys.

There are many abuses coming to light being inflicted on elder seniors when they are hospitalized.  Most of us already know older ICU patients have been targeted by hospitals to quickly discuss DNR status without doctor involvement.  Once this is obtained, hospice as “comfort care” is advanced to whisk the patient out of the costly ICU, saving much of the hospital Medicare DRG payment which goes into their coffers.

The most recent assault is interpretation of Advanced Directives and other legal documents by personnel, including the hospital-run Palliative Care Team.

Here is a recent scenario:  Mid-80s female admitted to the ICU with an acute stroke.  She is obtunded and cannot make medical decisions.  Her son is legally deemed to be her voice and make medical decisions.  The patient has an Advanced Directive signed 15 years earlier, but there is a POLST from two years ago.  Both say no artificial feeding. 

The son though states everything should be done as the patient’s wishes have recently changed.  However, the doctor states their HMO lawyer feels the son is not following the patient’s past documented wishes.  The son advises the doctor and hospital to place a feeding tube, which initially they refuse to do. The son pushes back and threatens to sue the doctor, HMO, and hospital.

This was brought emergently to the hospital Ethics Committee where the HMO continued their assertion, and the hospital brought up Probate law to support their stand.

Fortunately during this time, the patient regained consciousness and told her son and physician she wanted everything done including the feeding tube.

There are Elder Law specialists who deal with these matters, and we intend on obtaining their opinion – hopefully in time for me when I get on Medicare next year.

I now know the hospital (as well as HMO) tactic is to throw legalese at families when they are emotionally distressed with the health of their loved one.  This son knew better and pushed back.  What about others who succumb to the pressure?

Here are lessons we should learn from this: 

-Keep your wishes up-to-date in legal documents should you be hospitalized.

-Know you can verbally change past decisions at any time without a change in your documents as long as you are deemed mentally competent. 

-Should you want to make a change in a past document, tell your appointed power of attorney immediately.

-Make sure your power of attorney knows she/he is your voice and speaks for you in any medical decision which should coincide with your wants and desires.

-Have end-of-life discussions well before illness or hospitalizations.

In a way, I look forward to being on Medicare.  But I look forward even more to not only keeping my power of attorney abreast of my personal decisions, but also revamping old documents assuring no one other than myself makes medical decisions for me, even if that voice comes from my power of attorney.   

Finally, I do not want hospital personnel to act surreptitiously for their financial benefit at the expense of my personal medical needs.

Gene Uzawa Dorio, M.D.