When my mother was facing her own end-of-life (EoL), over 10 years ago in Montréal (Canada), she had a fairly clear idea of what she did – and didn’t – want in terms of medical interventions. I’d gone back to school to complete a Masters’ degree in bioethics, so we’d discussed her EoL wishes at length as she became progressively sicker over the course of a few years.
Unfortunately, despite being very well-informed on EoL issues, she encountered difficulties in both obtaining a do not resuscitate (DNR) order and then in having it respected. And this was despite having a daughter specializing in bioethics, who had medical power of attorney for her and was usually present when her medical treatment decisions were made.
First off, the hospital in which she was cardiac intensive care unit (cICU) patient required a number of individuals – within that hospital – to authorize the DNR; the treating physicians for each of her 3 life-threatening comorbidities (cardiology, endocrinology, and pulmonology), a member of the psychiatry staff, and a representative of the chaplaincy program.
This was a paper document, requiring wet ink signatures for these 5 individual assessments (and I believe written evaluations) of my mother’s medical status, mental status, and overall ability to comprehend the impact of her DNR request.
In Québec, even now, “In health establishments, there is generally a presumption in favor of life, so that when cardio-pulmonary arrest occurs, cardio-pulmonary resuscitation is performed, unless there are explicit orders to the contrary in the record.
The presumption in favor of life seems to seek the patient’s best interests. But in fact, the requirement to write the order “do not resuscitate” in the patient’s record presupposes that the patient would consent to resuscitation.”(1)
In certain hospitals in this province, at the time, the view that “The presumption in favor of life seems to seek the patient’s best interests” seemed to override even a DNR. It wasn’t overtly stated in my mother’s case, but rather the DNR would be ‘lost’ or ‘go missing’ from her records in 2 specific hospital centres.
By the time she passed, after 2 years during which she spent more time in hospital than out, I’d taken to carrying notarized copies of her DNR in my purse.
At one hospital in particular, the nurses who knew her best in the cICU worked out a system with me. Whenever it seemed that my mother might be taking a turn for the worse, one of these lovely nurses would call my cell phone…
I’d leave my office, taking an immediate lunch break, and drive 25 minutes to the hospital; the nurse or one of the orderlies (who’d have been described to me by the nurse who’d called) would wait at a side door of the hospital, at the 25-minute mark, for me to drive up and hand them a notarized copy of the DNR.
If it seemed that resuscitative measures were about to be taken, the nurse would breeze into my mother’s cICU bay and announce “Mrs. X’s daughter just brought in a new copy of the DNR, as she noticed that it seemed to be missing when she was here last evening.”
I know that this was done at least 3 times; it may have occurred more often, as 2 of the nurses had asked to have ‘their own copies’ of my mother’s DNR in the event that they couldn’t reach me in time.
Today is the 12th anniversary of my mother’s death, so I’m using this as a impetus to post a few items on EoL. As an aside, the situation at this specific hospital has improved since 2003, so I’m hopeful that no other terminally ill patients risk having their DNRs ‘lost’ or ‘misplaced’.
References
(1) College des médecins du Québec (Québec College of Physicians). Legal, Ethical and Organizational Aspects of Medical Practice in Québec: End-of-Life Issues – “Do Not Resuscitate” Order. 04 Apr 2011. Web: http://aldo.cmq.org/en/GrandsThemes/EnjeuxFinVie/OrdonnNonReanim.aspx