Dying is difficult, we need to get our paperwork in order beforehand. Among the important directives we must all do before we die (living will, medical power of attorney, durable power of attorney, last will and testament), there is the medical order for scope of treatment, sometimes known as the do not resuscitate order. This form is a one-page, two-sided document that summarizes in check-box style choices for key life-sustaining treatments, including CPR, general scope of treatment, antibiotics and artificial nutrition/hydration. For each type of treatment, the patient may refuse treatment, request full treatment or specify limitations.
The MOST/DNR includes:
- CPR clause – Do we want this? Yes or no.
- Medical interventions that are possible: Full Treatment – the primary goal is to prolong life by all medically effective methods – ventilation, intubation, defibrillation (shocking the heart), or giving specific medication like epinephrine, that can help restart the heart. Selective Treatment – the primary goal is to treat medical conditions while avoiding burdensome measures. Comfort-Focused Treatment – the primary goal is to maximize comfort, but no life-sustaining treatments.
- Do we want Artificially Administered Nutrition/Hydration – feeding tubes – permanently, short term or none?
- Who has the doctor discussed this with – patient, medical power of attorney, etc., ourselves?
The document must be signed and dated by a doctor and yourself.
The reverse side of this document has strict orders to follow for all health care professionals.
Unfortunately, these directives are not always honored. A recent New York Times article said many doctors override DNRs because of not being aware of them in the patient’s files; the doctor’s discomfort with letting someone die; litigation; underlying conditions that make the situation more complicated to assess; the necessity of surgery that could suspend the DNR; national databanks tracking mortality in hospitals that can reflect poorly on hospitals; and language interpreted differently across medical settings and is not always consistent.
Mercy/CommonSpirit’s policy is:
All patients in our care will be resuscitated, when clinically justified, unless a CPR Directive or other advance directive specifying “No CPR” is apparent, known, and immediately available. If someone has a readily available CPR directive, we will honor it. We encourage everyone to have conversations with their loved ones to express their wishes and name a proxy decision maker in the case that lifesaving and/or life-sustaining treatment is considered.
Maybe we need to wear these directives around our necks.
Animas Surgical Hospital is mainly a surgical site, so they don’t often deal with illness and death. It does honor our rights to make any health care decisions stated in the Colorado Hospital Association Rights, which honor all advanced directives, including the DNR:
Your right to refuse treatment: Once you have been fully informed about a proposed treatment, you have the right to refuse. You can refuse any medical treatment at any time for any reason, even if you might get sicker or even die as a result.
If an accident deprives us of our agency, will the health care system honor our wishes if our medical power of attorney can’t be present soon enough? Some surgeries and procedures cannot be performed without a breathing tube, but the patient should be able to request that certain things be off limits depending on the circumstances.
It’s important for those of us who do not want any intervention when our time comes to appoint a trusted medical power of attorney, a health care representative. For many individuals, finding a willing and competent HCR is very difficult. Relatives may be unavailable or incapable of fulfilling that role. We need people who can accept this responsibility, are willing to be tough with the medical establishment and who will be able to detach the tubes as they say, because they know deep in their hearts what we want and are willing to fight for it.
There is a continuing excess of unwanted medical care, particularly at life’s end. Here is another situation where we need to take control of our health care, our medical procedures and our deaths. And may we all have our wishes in order, and on paper.
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Martha McClellan has lived in Durango since 1993 and has been an educator, consultant and writer. Reach her at mmm@bresnan.net.
