YOU DO UNDERSTAND ABOUT DNR? A simple surgical procedure ends in a question about end-of-life decision making
Goerner, Leslie
YOU DO UNDERSTAND ABOUT DNR? Don't you? Don't you? Leslie Goerner Four years ago, my mother underwent a routine hospital procedure to verify the suspected presence of an ulcer. Strong-willed in...
...You may be asked to sign something...
...I must have gasped...
...For years we had been unable to persuade her to eat properly...
...There I was, signing permission for every one of them...
...Our lives could return to normal...
...Now she could start telling everyone just what she thought of this fiasco...
...The fact was, I had been thinking...
...Poe might have relished such a scenario...
...Why exactly are you even mentioning such a thing...
...she nibbled on quartered lunch-meat sandwiches, her mainstay...
...Physicians today are being pulled in several directions at once...
...And very particular...
...Don't worry, Mom," I called after her, "they won't...
...Again he prodded: "I was just wondering whether your mother ever mentioned anything to you...
...She mentioned the option to me and said she probably ought to get it out of the way in the event that it might someday be needed...
...Each of four specialists had a different theory, a unique approach...
...Austin went on to explain that my mother might need the help of a respirator...
...As medical specialists and staff continued to offer no hope for her recovery, might I at last have submitted, signed the DNR order, and so consented to her death...
...Yet we all stood by, waiting for her to take responsibility...
...What many people do not understand about DNR-what my mother and I did not know- is the definition of "heroic" as it is carried out in practical application...
...Meanwhile, she kept an open bag of corn curls propped by her chair...
...She doesn't eat," I replied...
...She lived to celebrate the birth of two great-grandchildren and the ongoing support of her family...
...Kept alive by a respirator, then an oxygen mask, IV, and feeding tube, but in essence by the gracious will of God, she walked away from the obstacle course a still-frail woman not the slightest bit anemic, with one tiny ulcer already mending...
...After three days, Dr...
...She nodded and mouthed the word, "Okay"-over and over again, "okay...
...For the first time in years she was able to attend church regularly...
...Or would doctors have been required by law to abide by "wishes" she would never have expected could end her life before the fight was lost...
...I prayed for my mother's full recovery Two days later, no evidence had yet been found in Mom's bloodwork, x-rays, or the failed endoscopy to indicate any serious medical condition...
...Instead he asked: "Has your mother ever indicated her feelings regarding artificial life support...
...Just leave it in the fridge...
...She's much too thin-severely malnourished," they worried...
...Yet she was failing...
...A story had long since begun to play out in my mind, its setting a sterile hospital room where a woman slowly suffocates...
...But it wasn't...
...At her bedside, I reminded her of everything that had happened...
...I did not stand guard alone...
...She's stubborn...
...The sun rose on schedule...
...Moments before I arrived, she slipped away in her sleep...
...The head nurse said that, if such a thing exists, my mother's death was beautiful...
...At that moment, I became connected to a machine...
...When, a week later, my mother failed for the third time to be weaned successfully from the respi-rator, her cardiac specialist expressed a different attitude: "Sooner or later," he admonished, "you'll need to make a decision about how far you want to carry this...
...My mind stalled...
...Austin (not his real name) visited my mother to describe an endoscopy...
...Instead, routine turned into a fight for her life...
...In fact, years earlier, I'd been with her when she consulted her lawyer about a "do not resuscitate" order (DNR...
...one of the nurses asked kindly...
...Whenever I delivered homemade meals, often her own recipes, she'd take a few bites or say, "I'm not hungry right now...
...Immediately she had begun to struggle for breath...
...So followed weeks of disobedience: four CAT scans, a scoping of the heart, two more endoscopic procedures, countless blood tests attended by the installation of tubes to ease the process, daily x-rays of the lungs...
...He'd be finished in an hour, he assured her...
...she wasn't...
...She's severely anemic," he replied blandly...
...Even as we spoke, she grew visibly weaker...
...And then they closed the door...
...Or would it...
...In case of an emergency, we wouldn't want to be without instructions regarding your mother's care...
...Soon after Dr...
...Strong-willed in every inch of her five-foot frame, at seventy-three she had suffered no major health problems...
...The night before the procedure, Dr...
...All I could do, going out or coming in, awake or late at night reawakened, was pray: "Let my mother live...
...When, like a coach to a profoundly weary player, I urged her to try, to inhale, she whispered breathlessly, "I can't...
...Without quite knowing why, I lied...
...What are you going to do when this happens again...
...Well, it could be irreversible...
...Please let her live...
...I told him she hadn't discussed the matter with me...
...People don't have to die from spontaneous pneumonia, do they...
...In her kitchen I'd find a trail of wrappers from candy and packaged bakery goods...
...the moon and stars retained their midsummer patterns...
...For legal purposes, the term includes the use of a respirator to pump oxygen into the lungs...
...I began at last to understand the extent of her peril...
...For a moment, I felt selfish, unreasonable...
...Austin to tell me how he proposed to clear her lung...
...As the ICU team prepared to insert the tube in her mouth, my mother, confused but still feisty, showed some resistance...
...Just think about it...
...But that was not to be...
...As her ailing joints began to make cooking a hardship, I applied to Meals on Wheels, which Mom promptly canceled...
...My family upheld me with prayer, love, and constant thoughtfulness...
...Then from the other side of the bed, a burly attendant who had just been caring for my mother's needs looked earnestly at me and said, "If she doesn't go back on the respirator, you know what will happen...
...Austin had ordered oxygen...
...The plate usually remained untouched...
...she'd be home the following afternoon...
...Two months after what was to have been a routine examination, my mother came home from the hospital...
...But I was reminded of the second chapter of James's epistle where he tells us that refusing to provide life's necessities is the epitome of a dead faith...
...Why couldn't I sign in advance...
...Having evaluated the level of her distress, Dr...
...Other worries also shadow this near tragedy...
...At the main ICU desk, the hub of several curtained suites, I signed instead a legal permission slip to employ the inhalator...
...Ignoring her muzzle-like oxygen mask, she kept issuing garbled instructions...
...No more tests...
...It was something she planned on signing but never had...
...Of course she wants it," I gasped...
...Then, upon admission to the hospital the day before, she had received a form in her information packet: standard material for all incoming patients...
...Might I in fact have caused it...
...Throughout the day, she drank her coffee and munched her treats...
...Brought in on what had become my mother's "case," a lung specialist in his mid-thirties barely introduced himself before asking what was to be his only question: "I presume you've been told about DNR...
...But only for a moment...
...The second time I signed for my mother to be assisted by a respirator, an ICU nurse said in a confidential tone, "Be sure to ask the doctor what it could mean...
...Austin had delivered his news, I followed my mother, alert on her stretcher, up to the hospital's critical-care unit...
...What-ifs that aim to reconstruct the past are vain illusion...
...pneumonia, a typical result of aspirating foreign matter into the lung...
...Sometimes," he offered quietly, "a person will make a comment to a family member about not wanting to be resuscitated...
...People typically associate DNR with terminal illness or critical injury, times when machines can become a hindrance to the process of mortal passage: no heroic measures...
...Commonly referred to as a living will, the DNR document directs professional caregivers to take no heroic measures in an effort to save a person's life...
...Dr...
...Had my mother signed the standard health-care proxy issued to every patient, would she have survived her ordeal...
...Day and night, I kept watch in my mother's room, where something worse than death was lurking...
...But I felt numb, incompetent...
...Although disturbed and saddened to hear of my mother's complications, I waited confidently for Dr...
...About life support...
...The thought curdled in my mind: what if they couldn't locate me...
...on her own, Mom still could not get enough air to oxygenate her blood...
...Vomiting, she had aspirated the contents of what should have been an empty stomach into her left lung...
...And that is a terminal illness...
...I studied nuances from the night chart, written comments of doctors interpreted by sympathetic nurses...
...My mother left this world just as morning was breaking...
...Surely, I thought, aspirating into the lung would not qualify as a reason for halting efforts to help a patient breathe...
...As the dying woman grips with the strength of residual panic the hand of her betrayer, the daughter offers tearful prayers for recovery...
...I asked...
...I do not wish to be kept alive by artificial methods...
...The attending nurse advised, "Stay close...
...In the waiting room, I listened as the doctor described how his patient had become nauseated...
...Another round of blood work and x-rays confirmed what anyone could see...
...Austin removed Mom from the respirator...
...Clearly, this was no rerun of "Marcus Welby, M.D.," where the mild-mannered hometown healer steps forward to battle the forces of death...
...Still conscious, still alert, but too weak to beg for mercy, she stares into the eyes of the daughter who has cut off her oxygen supply...
...Emotions advanced and receded out of context...
...Austin made the decision to hook Mom up to an inhalator, but not before asking me a fourth time to consider a DNR order...
...Again, she did not follow through...
...Oxygen-deprived, disoriented, Mom had no idea what she needed or why...
...You know what just happened to my mother...
...Yet sometimes speculation can instruct the future...
...She weighed eighty-six pounds...
...As members of the ICU team wheeled her into Observation Room 3, she invested her last full gulp of air: "You're not going to run any more tests on me...
...She enjoyed the best of care...
...This happens sometimes when the digestive system gets sluggish," he said...
...When you continue to put patients on a machine, you reduce their chances of breathing again without it...
...Happily, for more than three years after this incident, my mother remained independent in her own home...
...The test involved passing a flexible lighted tube through the mouth and esophagus into the stomach...
...I had just inherited my mother's anger...
...Do you want this...
...The nurse should have checked before sending her down...
...It can also mandate the withdrawal of nutrition and hydration: food and water, intravenously provided...
...Their dedication to restoring health, traditionally the single focus of the medical profession, is being challenged by moral and ethical dilemmas caused by advancing technology and its enormous costs...
...In 1996, she moved to a nearby nursing home where she made friends among fellow residents and staff...
...She didn't like gravy and couldn't trust anyone to remember not to serve it to her...
...On one issue, however, they concurred: Mom had a life-threatening illness...
...Already, he said, he had contacted the intensive care unit (ICU) on the assumption that she had Leslie Goerner, a free-lance writer, lives in New Hartford, New York...
...Everyone, from health-care professionals to patients and their relatives, needs to be aware of the subtle ways in which legitimate concerns about costs and personal autonomy can erode care and even our regard for the sanctity of life...
...my mother had insisted...
Vol. 124 • November 1997 • No. 20
