To sign or not to sign a DNR is another tough choice patients and families have to make. Signing a DNR is making the statement that if the patient dies, CPR will not be done, and paramedics will not be called. That is a tough decision for many families, so it’s always best when a patient has planned ahead. If a person has already completed advance directives and indicated their choice, that choice should be honored as closely as possible by the power of attorney representing the patient.
CPR was not originally intended for use in situations where patients were dying of old age or terminal illness. The procedure was intended as a method for reviving trauma patients. Unfortunately, the elderly will often end up with broken bones and more clinical issues than they had before CPR was done. For terminal patients, CPR is only reviving them, if successful, just to die again of their terminal illness.
An elderly gentleman whose wife was on our service went into a panic as she was dying and called 911. She had already died when paramedics arrived, but they were able to revive her and took her to the hospital where she was intubated (had a breathing tube inserted) in the ICU. When he went to visit her and saw all the tubes coming out of her and all the machines around her bedside, he realized she did not want any of that. He gave his permission for everything to be stopped. He watched his wife die two times in the same day.
The goal of the hospice when a patient has a DNR is to make certain that suffering is alleviated as the person begins the active phase of dying. The DNR is always revocable.
It is not mandatory to sign a DNR when enrolling for hospice in most instances. Many health professionals are surprised to learn this because they do not really understand the issue. When patients come on hospice in a facility, the staff often assumes that the patient has a DNR. In the instances when the patient or family was not ready to sign a DNR, staff may become indignant and angry. They think the family is in denial because the hospice is a place where a tranquil death can be achieved, not a place for ongoing treatment.
I remind those involved that this is a very tough emotional decision and if the family needs more time before they are ready, that is acceptable. In addition, social workers, chaplains, and nurses will also address the issue and help the patient and family come to acceptance of the inevitable. Emotional issues are not easily resolved with arguments based upon practicality.
Sometimes the patient indicates they want everything done and they do not want a DNR. I think it is important to honor that choice. Where a lot of families find themselves unsure of what to do is when the patient is no longer responsive and the family feels an obligation to continue doing everything possible because that was the wish of the patient when they were responsive. In a situation like this, it is important to have a discussion with medical professionals and determine if there really is anything more that can be done, and if not, consider the option of signing a DNR and letting the patient go in peace when they are ready to stop the fight.
If you have particular questions or need support for specific concerns, you may click the consultation tab above or send an email. Find more support for your experiences with terminal illness, and death and dying by reading The Fine Art of Dying.