DNR - What is it and who should know about it and why? Is this a Living Will?

Does a DNR order really mean DO NOT RESESCITATE ever, under any circumstances - or does it mean do not resescitate only under these specific conditions? Have these conditioins been documented in the DNR order? Does the family have a say? Does the family have a say even when the patient has been clear about their wishes and has a written directive? Who should be aware of this directive and who is obligated to honour it? Under what circumstances? Where does one keep a copy of this directive? These are just some of the many questions that arise when one speaks about an order to not attempt resescitation.

The same questions can be asked of the more specific directive of "no CPR". Does the patient really mean "no CPR" under any circumstances or is it intended to have a more limited meaning, e.g., no CPR only if recovery is remote or there is no chance of recovery? What about "No More Chemotherapy" requests? Are any of these different from the other? I would suggest that 'yes' they are very different.

Notice the change in language from the DNR directive to the "No More Treatment" request. As we move from the word 'directive' to the word 'request', there is an assumption of choice here. And, there is when the word 'request' is used. On the other hand, the use of the word 'directive' is purposeful in that a DNR directive is a request that a medical professional is legally obligated to honour - if they know about it that is. And here is the clincher for many people - "if they know about it."

The law is very 'fuzzy' in this area and I would suggest it is very 'fuzzy' with intention. Death is a difficult subject in our culture and no one wants to believe or acknowledge that someone could possibly wish to have an end to their life (I would argue, an appropriate, autonomous end in the case of DNR orders!). By allowing this 'loop-hole' to exist in the legistlation, it makes room for a desperate family to remain hopeful and it allows the 'miracle of modern medicine' one more opportunity to work. We have to remember that we live in a culture that believes, often against the odds and valid research to prove otherwise, that the right treatment can fix anything. We have lived within the bio-medical model of healthcare for so long, that it is imbedded in our belief system - cure is the only reasonable alternative! So where does that leave us with orders to DNR?

I posed some questions at the beginning of this blog - hopefully just to get us thinking about the difficulty behind making decisions like these and almost as importantly, around honouring these decisions. It has been suggested that a 'Living Will' is one of the best ways to protect your wishes surrounding EOL directives. A Living will is a document that one fills out and signs, which clearly lays out any specific directions a person might have regarding how EOL care and treatment are handled and delivered. It may include such things as: the use of extraordinary care; life-saving treatment options; life-preserving treatment options; specific treatment choices; where one would prefer to die; who one would prefer to be (or not be) with them; wishes around pastoral care; DNR orders; the list is endless really. Once this document is completed and signed, it is imperative that a discussion takes place between family members and other caregivers (in the event that this is being done during a time of illness), with the family doctor, other members of the healthcare team and of course, your lawyer. A copy of the document should be kept at home, with your lawyer and with your doctor, minimally, at whatever point in your life you choose to complete it. If it is completed during a time of terminal illness or life-threatening illness, it should be even more widely distributed in order to ensure that your directives are followed in the event of an emergency medical situation. It is not unheard of for a family to disregard their loved ones wishes simply by saying they did not know about the document or that they did not have access to it. Care must be taken by all involved to opening discuss the decision and its implications for not just the patient, but for those who will be left grieving their loss.

The above suggestons are merely that, suggestions. A Living Will or a directive to DNR are only as good as the people that know about them! Really.