“That 81-year-old female that came in with altered mental status, the chest x-ray show she has pneumonia. I started the antibiotics. She’s gotten a liter of fluids but her pressure is still low. I’ve page the ICU resident to get her admitted,” the physician assistant explained to be attending emergency physician.
“Didn’t you tell me before she was DNR?” the physician replied.
“Yes, she is.”
“Then cancel the ICU. She can be admitted to the floor.”
Critically ill patients with pneumonia are three times more likely to die if they are not admitted to the intensive care unit from the emergency department. This scenario, in which a patient with a Do Not Resuscitate (DNR) order is assumed not to want care in the intensive care unit, is a regular occurrence.
Advance Directives are medical decisions that people make to be carried out should they become too sick to tell the doctor themselves what treatments they want or do not want. Many people for very good reasons want a DNR order as an advance directive, meaning if their hearts stop beating and they stop breathing then they do not want attempts to be made to restart their hearts with CPR or defibrillation. But what is it about DNR orders that leads emergency physicians and other providers to presume that these patients do not want other types of care? In what way does a DNR order lead them to conclude that an 81-year-old woman with pneumonia does not want to be admitted to the intensive care unit? And yet that is the current practice in emergency medicine.
A health care proxy is a person you designate to make medical decisions for you if you cannot make them yourself. In Massachusetts, we have the benefit of a Roman Catholic Health Care Proxy form. It is very similar to the proxy forms you get at hospitals, but also includes choices consistent with our Catholic faith, like calling a priest to administer the Sacrament of the Sick, and providing food and water—even through artificial means—unless our lives are at their very ends.
The person you choose as your proxy should share your Catholic values regarding health care. He or she can make decisions for you in circumstances where the outcome may be unclear. She may ask the doctor to try a treatment and if your condition does not improve, request that the treatment be stopped. Your proxy needs to be someone that can make decisions like these, who will consider each situation when it occurs, rather than you deciding in an advance directive that you never want a treatment no matter what the situation.
In today’s health care climate, we are far more likely to have treatments withheld rather than given excessive treatments that unnecessarily prolong our lives. In fact, we have to ensure that ordinary care, such as food and water, are given. Such a climate is a dangerous one, indeed, for physician-assisted suicide. We need to care for life until natural death, not hasten it to an end to preserve something as ambiguous as “dignity.” Life itself has dignity.
A person’s autonomy is not being respected by the medical community when it over-interprets a DNR order or other advance directives. Sadly, this means you should not have any advance directives if you want the best chance of receiving all beneficial medical treatments. Every adult should complete a health care proxy form so that someone you trust will make decisions for you when you cannot.
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