Honorable Mention in our 2001 writing contest

DNR: Did Helen still want to die?

Did this doctor violate her patient's last stated wish, or had those wishes changed? This story carries a powerful message.

By Christie Murphy, DO
Internist/Cuyahoga Falls, OH

I 'd just closed my eyes, hoping for a few minutes of sleep during a hectic night of call, when my pager went off, yet again. By then, I'd already dialed the emergency department so many times that all I needed to tell the unit clerk was, "It's me."

The ED doctor's tone was urgent. "We have an 80-year-old female who called the first aid squad because she was having trouble breathing. Blue when they arrived, and the paramedics tubed her. Down here on the vent. Needs to be admitted to the ICU." He was too tired to speak in full sentences and was moving on to another patient.

A moment after I stepped into the ED, alarms began sounding from the monitor on the other side of the room. Hurrying to the bedside, I quickly realized I had to take action on this patient's 80/50 blood pressure and 200-beats-per-minute heart rate. Glancing at her face, I saw that it was Helen, a woman I'd treated in the ICU just weeks before. Heart failure had put her on a ventilator at that time, too. Pointing to a letter board, those same red fingernails had spelled out T-A-K-E-M-E-O-F-F.

But as the nurse arrived with the crash cart, the memory faded and instinct took over. I tried medication first, but Helen's BP dropped to an unmeasurable level, and her heart rate didn't budge. Not until I yelled "Clear!" and activated the charge on the paddles did the alarms cease and her heart rate become controlled.

Time passes quickly during a code, but I knew it had taken a long while to restore adequate blood flow to Helen's brain. I wasn't sure how much damage had been done. As I contemplated which drips to order, I heard a familiar voice.

"Doctor, is my mom okay?"

I turned to look at Helen's son and saw the terror in his eyes.

"She said she didn't want to be on that machine, remember?"

My mind again drifted back to my last encounter with Helen. It was her fourth time in the ICU that year, and she was improving but not yet ready to be weaned from the ventilator. I'd taken her off sedatives in hopes of getting good weaning parameters, so she was alert. Biting on her endotracheal tube, trying to talk, and pulling on her restraints, Helen had gotten my attention. Using the spelling board, she made clear what she wanted. I explained that taking her off the ventilator wasn't a good idea. She looked at me attentively and nodded as I outlined my concerns about her unresolved heart failure.

"Do you understand that you may die if we take you off the ventilator?" I asked.

Helen's fingers moved to the letters Y-E-S.

"But is that what you want?"

Y-E-S.

Her son had witnessed this exchange and had agreed that we should take her off the ventilator. Helen was extubated. After a few days in the ICU, a 100 percent nonrebreather, and a lot of diuretics, she made it to the medical floor, then back to her apartment.

Before her discharge, we talked about DNR status. I suggested she get a bracelet indicating she didn't want CPR. I told her to put a signed order on her refrigerator at home and in her hospital chart. She agreed. Her 80 years had been good ones, she said, and she didn't want to prolong her passing with ventilators.

Back in the present-time ED, I looked down at Helen's wrist. No bracelet. "The paramedics didn't know," I told her son. "They intubated her before she got here."

With tears rolling down his face, he asked, "What do we do now?"

An excellent question. I was torn. Did Helen still oppose being resuscitated? Had I just acted against her wishes? Why hadn't she gotten a bracelet and an order? "I'm not sure," I replied. "She can't tell us what she wants now."

Although Helen had already expressed her wishes, it bothered me that she'd called the squad asking for help and had never gotten a DNR bracelet. Maybe she'd changed her mind.

I told her son that I thought we should transport her to the ICU, treat her heart failure, and hope she would wake up and be able to give us direction. We could take her off the ventilator later if she didn't improve, but if we extubated her now, she would die.

He agreed, and we returned to her bedside. "Why is she so still? Did you give her medicine to make her sleep? Her eyes are closed."

"Helen had a low blood pressure and a very fast heart beat for a long time," I answered. "I'm not sure how well her brain is working. It may never work. It's hard to tell right now."

More tears flowed as he took her hand.

"Mom, it's me. I know you don't like this machine, but I don't know what to do. I need you to wake up and tell me what to do. Please tell me what you want me to do."

If I had been more awake, and if it weren't 4 am, I never would have believed what I saw. Helen's hand curled around her son's fingers.

"She squeezed my hand," her son said. "We did the right thing."

Early the next week, back on the medical floor, I was writing in a chart when I heard a wheeled walker approaching fast.

"Hi," said a voice I was sure I'd never hear again. Pulling her gown aside and pointing to faint burn marks on her chest, Helen said, "Did you do this to me? It sure is sore."

"Yep, I did that," was all I could utter.

"Thanks. And I decided that machine isn't so bad. Forget about that DN-whatever." Then off Helen rolled.

I'm not sure how long I stood there with my mouth wide open, but I should have watched Helen longer, because that was the last time I saw her. Several months later, I received a note from her son. "I found Mom in her bed," it said. "She was gone. I'm glad it happened that way. We did the right thing. Thank you for two more months with her."

After that experience, I've never looked at a code, an ICU, or a patient the same way again. Now before writing an order or prescribing a drug, my first thought is, "What does the patient want?"

Helen also taught me that the paddles hurt, and that red nail polish still looks good when you're 80.

 

Christie Murphy. DNR: Did Helen still want to die?. Medical Economics 2002;10:50.