Post 6: Who Do I Tell if My Mom Does Not Want Resuscitation Attempts? - A Three Step Process
Updated: Dec 18, 2022
"My wife one time was in the hospital, and she said they gave her four electric shocks. She told me she would never want to go through that again. I tried to tell the paramedics the day she died, but they gave her shocks anyway."
The default in the United States, almost always, is to attempt resuscitation when the heart stops (Read Post 5: CPR on TV versus CPR in Real Life - Three Ways They Differ).
In times of emergency when a person has gone into cardiac arrest, every second in which the heart is not pumping blood and the brain is not receiving oxygen via circulated blood is critical. Irreversible brain damage starts at around ten minutes of the brain not receiving oxygen.
Paramedics and other first responders do not have the luxury of asking family members the person's thoughts on resuscitation. If they do not detect a pulse, meaning the heart is not pumping blood in the body, they immediately start CPR (cardiopulmonary resuscitation).
Resuscitation attempts may also include electric shocks via pads or paddles and medications pushed through an IV (intravenous) needle, which is a needle inserted into a person's vein.
If paramedics or ER (emergency room) physicians are able to resuscitate the heart so that it resumes beating and pumping blood throughout the body, a breathing tube (endotracheal tube) is placed through the mouth into the windpipe (trachea) and the breathing tube is connected to a ventilator, or "life support machine," in the ICU (intensive care unit).
If paramedics or emergency room physicians are not able to resuscitate the heart and the heart does not resume beating, they will halt resuscitation attempts and declare or call the time of death.
"If my heart stops, I'm dead. It is my time. I want a natural death."
"If my heart stops, let me go. I don't want to die twice!"
"If God says it's time and he takes me, I will happily go with him. Don't try to bring me back."
If a person is sure that they would not want to experience resuscitation attempts - that they would want a natural death - what can they do to ensure this?
There are three steps to take to maximize the chances that wishes for a natural death, a death not interrupted with resuscitation attempts, will be honored.
1. Complete an OOH DNR (Out of Hospital Do Not Resuscitate) or EMS DNR (Emergency Medical Services Do Not Resuscitate) form.
Though the purpose is the same - to communicate a physician's order to first responders to refrain from attempting resuscitation and allowing a natural death - the actual name of the form differs by state, ranging from OOH DNR (Out of Hospital Do Not Resuscitate) to EMS DNR (Emergency Medical Services Do Not Resuscitate).
For the sake of brevity, I will use OOH DNR to indicate all of these forms.
A universal requirement is at least a physician's signature (some states also allow a physician's assistant's or nurse practitioner's signature) so that the DNR becomes a "doctor's order." First responders can then follow this "doctor's order," allowing them to honor a person's wishes for a natural death.
If a person completes an OOH DNR form and later changes their mind, they can put away the OOH DNR form and communicate to their family and healthcare providers their most updated wishes. A person can change their mind either way at any time; this usually happens when there is a major change in their medical or health situation.
Blank OOH DNR forms can be printed from an individual state's public health website. Many hospitals and physicians' offices carry blank forms.
Most states honor the completed OOH DNR form of another state. If you move, it would be best to confirm if your new state honors another state's OOH DNR form.
2. Post the signed OOH DNR form in a visible place.
After the OOH DNR form is completed and signed by a physician (or, in some states, physician's assistant or nurse practitioner), the form should be posted someplace visible where paramedics and other first responders can see in case of emergency. Common examples are the refrigerator door or over the bed of a bedbound person.
A copy or the original can be posted. Copies are honored as the original.
First responders will not have the time to search the house nor call family members about potential documentation. If they do not immediately see a completed OOH DNR form, they will not know about the person's wishes for a natural death.
The default in the United States, almost always, is to attempt resuscitation.
If a person frequently leaves the house, they may choose to keep a copy of the completed OOH DNR form in their purse or wallet. If a person stays in one daughter's house on the weekdays and in another daughter's house on the weekends, both daughters should keep copies of the completed OOH DNR form in their respective homes.
The completed OOH DNR form, copy or original, should follow the person.
3. Communicate DNR, also called DNAR (Do Not Attempt Resuscitation) or AND (Allow Natural Death), wishes to healthcare providers with each change in setting.
There is no such thing as over-communication because the default, almost always, is resuscitation.
Each time a person is admitted to the hospital, they must communicate their DNR wishes. Verbal communication is usually adequate for the healthcare team to then write a DNR order in the person's hospital chart (some states may have more requirements).
The DNR wishes may not be easily visible, or saved, in a particular hospital system's electronic record so DNR wishes should be communicated with each hospitalization, even if the person had previously been admitted to the same hospital.
Silently providing a copy of a completed OOH DNR form to the hospital medical team is not adequate because the OOH DNR is a physician's order that pertains only to the "out of hospital" environment.
Providing a copy of the OOH DNR is helpful in that it triggers the hospital team to ask a person about their resuscitation wishes. Otherwise, a person is frequently assumed to be a "Full Code," which means attempt full resuscitation attempts if the heart stops pumping.
DNR wishes should be communicated in each new setting - hospital, rehab, nursing home, clinic.
When a person returns home from the hospital, the purple DNR wristband the person had been wearing in the hospital is not enough to protect them at home. Each time a person returns home from the hospital, they must have their OOH DNR form posted in a visible location. If they gave their original to the hospitalist and never got it back, they can post a copy of the signed OOH DNR. The copy of a signed OOH DNR will be honored as the original.
The default to attempt resuscitation for any and all cardiac arrests, whether it be the 8 year old healthy boy who drowned in the swimming pool or the 80 year old bedbound man with severe dementia, is meant to protect all of us so we are all given time-critical care in extreme emergencies.
The default becomes a problem when we do not all want the same default care. Some people, at a certain stage in their lives, want to be allowed to remain at peace when the heart stops beating.
They want to be allowed to accept death.