xinabess Asked April 2017
How do you reinstate a DNR?
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After my mom's stroke last year, she said she did not want a DNR. I am her proxy and I haven't asked her about it lately, but I see that she's starting to decline and I really want the DNR. How do I make this happen?
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The Green Sleeve contains Advanced Care Planning documents and is the property of the patient. Before it is issued there is a discussion between medical staff and the patient called “Conversations that matter: Goals of Care." I will cut and paste some of the document provided by Alberta Health Services. There are three levels of care:
“Medical Care (M) – Medical tests and interventions are used to cure or manage an illness as well as possible but don’t use resuscitative or life support measures. This is appropriate when resuscitative and life support measures won’t work or when the person chooses not to have these treatments. Medical care can be given in many locations, depending on the person’s wishes and values as well as if it’s appropriate medically.
Resuscitative Care (R) – The focus is to extend or preserve life using any medical or surgical means. This includes, if needed, resuscitation and admission to the intensive care unit. Talk to your healthcare team about which Goal of Care designation best reflects your health circumstances and your wishes and values.
Comfort Care (C) – The focus of care is to provide comfort to ease a person’s symptoms without trying to control the underlying illness. This is for people who have a life-limiting illness, when treatments can’t influence the course of that illness. This care can be given in any setting.
Within these three main approaches to care (Resuscitation, Medical, and Comfort Care), there are sub-categories. These are used to further define and communicate your Goals of Care designation to healthcare providers.” (AHS website, April 11, 2017)
I would highly recommend that you access the Advanced Care Planning website devised by Alberta Health Care, the provincial (as opposed to federal) government department that is responsible for providing (free) health care to Albertans, and gives wonderful information about Advanced Care Planning. It is available in eight different languages including Punjabi, Vietnamese and Chinese.
https://myhealth.alberta.ca/Alberta/Pages/advance-care-planning-conversation-matters.aspx
In the “Other Places to get help” click on PREPARE. PREPARE is a program helps you make medical decisions for yourself and others, talk with your doctors, and get the medical care that’s right for you.
I hope this posting is of some help to all of you. Even though the AHS website is Canadian and there may be some differences, the basic concept remains the same.
First may I compare my situation with that of a young man called Ben. Although there was more than 30 years between our respective experiences but very similar circumstances, there was a huge difference in the outcome. We both, at 14 years of age, went underwater in a swimming pool. In my case, the pool was almost empty, someone realized immediately that I was in trouble, got me out of the pool and started CPR. Within 10 minutes I was sitting up asking what happened.
Ben was not so fortunate. He got caught under a piece of pool equipment and it was only when the pool was cleared that he was found. CPR was started immediately and, to the relief of everyone, his heart started to beat and he started to breathe on his own. It was a municipal pool and he got several million dollars in compensation—which is just as well— because he will need every cent he can get for his caregiving needs—now a healthy 19-year-old –but with a severe brain damage because his brain was deprived of oxygen too long. He can no longer walk, talk or see. He is confined to his bed or the chance of a change in his environment in his wheelchair. His lifespan is largely unaffected by his brain injury and he could, barring accident or injury, live for another 40-50 years.
As a CPR instructor, I taught my students that the first four minutes were imperative. After that the chances of a successful resuscitation diminished. Some institutions have an unspoken agreement to have a “slow code” i.e. no breakneck rush to get to the patient to start CPR but, instead, a “time wasting” period to delay the start of CRP, thus increasing the chances of a negative outcome. I, personally, believe that this is totally unethical but usually happens when the person who needs CPR should have had a DNR order in place—but didn’t. However, a slow code goes against the wishes of the patient/family and we, as health caregivers, need to respect those wishes no matter how much we disagree.
Incidentally, other than me, and although I am aware that it does happen,I have never attended a successful resuscitation--on young or old.
This post is getting a bit long so I will add another sharing what we do about resuscitation in Alberta, Canada.
She has previously told you and perhaps others differently (rejected her DNR), so you may have difficulty now in overriding her decisions without petitioning for guardianship, which you should really try to avoid. Remember that as her health care proxy, you are supposed to do what she would want to do herself. If you don't know that, you are supposed to use substituted judgment: knowing what you know about her, what she has said in the past, her values, you are supposed to step into her shoes and do what you THINK she would want you to do. This may be different than what you yourself would do if YOU were in that situation.
Going through the process of signing a MOLST should make her wishes clear, and take the burden off of you.
My mother didn't have a living will or anything but the Doctor advised against using life support but we all had to agree. I had to talk to my dad and sister and get them to see reason. If you're put on life support, you don't get to choose a time-frame and this is what my sister and father didn't understand.
You can talk to Clergy, someone in Hospice - there are plenty of people you can talk with. It isn't all DNR or nothing.
When she was in hospital my siblings and I discussed the DNR. They all thought she should have one. I explained what would happen if she didn't have one to her. Besides cracked ribs, the intubation and likely never returning home. She just said I want to live, not die. If I try and talk to her about DNR I feel she is seeing it as I want her to die.
She has lived with me 10 years. I know she wouldn't want intubation. She may change her mind down the line. When the idea of death isn't so close as it was at hospital stay. Then I fear it will be too late and her save at all costs plan would go in to affect.
If down the line something happened and paramedics came. Would they ask me about her wishes or just proceed with a full on CPR etc?
I mean, she finds it hard to sit in her wheelchair for more than 10 minutes lately, so the thought of her enduring anything as brutal as resuscitation is unbearable. Something is so very wrong with our culture that we can't accept the natural course of things and will do literally anything to change it.