It has come to my attention that patients showing up in Emergency Rooms with DNR (Do Not Resuscitate) papers in place are nevertheless being aggressively treated for their latest acute medical crisis. Sometimes the patient ends up intubated and on a mechical ventilator despite explicit instructions not to do so under any circumstances. Rationale for ignoring DNR documentation invariably circles around to the idea that DNR engenders too much of a "gray area" in terms of how medical professionals are to respect the individual's wishes. For instance, if a demented patient has a hip fracture and is in extreme pain, a daughter may decide to temporarily revoke her DNR-CC status and have the painful condition fixed. Or maybe the 94 year old guy in the passenger seat is rear ended by a pickup truck and slams into the windshield. He sustains a wicked scalp laceration and loses half his blood on the floor mats. The trauma staff in the ER wastes little time closing the wound and transfusing blood products. The tranfusions put him into failure and he is intubated. The next day he is weaned and extubated. He thanks the doctors and nurses for saving him. He goes home.
Clearly, DNR status is not always an inflexible, dogmatic guide to patient care. One needs to account for specifics and contingencies when composing DNR paperwork. Here is a sampling of my own attempt in a living will to outline a protocol for my care, accounting for circumstances. I have been as precise as possible only for the sake of clarity.
I, Buckeye Surgeon, being of sound will and mind on this day of November 12, 2012, make known my desires regarding the use and continuation, the withdrawal or withholding, of life sustaining treatment. If I am unable to give explicit instructions regarding the use of life sustaining treatment when circumstances find me in a terminal condition, it is my intention that this document should be honored by my friends and family members as a final expression of my right to refuse certain medical interventions in certain situations. I hereby declare that I am intellectually and emotionally competent to make this declaration.
If I am at least 85, but not more that the age of 99, and I suffer a severe cardiac event that results in multiple organ failure and my life hinges on the workability of various machines, please cease all efforts at trying to extend my life. If, however, I am over the age of 100, do not turn off those machines because I would like to have a chance at getting in the Guinness Book of World Records for "oldest living human" (although, as of now, I'm not entirely sure it would "count" if I was only being kept alive artificially, because wouldn't that allow frozen Walt Disney to get in on the game?). This avowal is declared null and void in the event my wife is still alive, due to the guilt I would have seeing her wheeled to my ICU bed every damn morning, all hooked up to oxygen and barely recognizing me anyway.
If I am between the ages of 20 and 50 and I foolishly decide to go daredevilling on an ATV, flip that ATV over, and crack 2 or 3 cervical vertebrae, thereby finding myself a quadriplegic, then you may take a loaded shotgun and insert the barrell into my mouth and fire at will. No, I'm just kidding. Besides, this document would not provide enough legal cover for anyone to carry out such an instruction. But seriously, do not put me in Christmas sweaters and shave my face and arrange for dental appointments to try to maintain the illusion of normalcy when everyone comes over for the holidays. I'm not saying for you to kill me or anything but please for god's sake don't dress me in khakis. Don't you dare try to make it seem like I have a body that needs 29 dollar pleated pants. I say, give me 18 months. Maybe I turn into one of those dudes who can blink out the great American Novel in some sort of ocular Morse code like that guy in The Diving Bell and the Butterfly. More realistically, I'll be begging you to get me on my way. So the directive is this: you may only save my life at the time of the ATV accident if you agree to construct a device that allows me to self inject 50 mg of Morphine with my tongue or whatever, if in fact I so desire at the 18 month deadline.
If I am at least 77 years old and am out for a morning walk when I am suddenly attacked by a rabid dog and lose consciousness, please do not hesitate to inject me with the rabies vaccine ASAP. If however, I am attacked by a pack of rabid wolves and, in addition to being inoculated with the rabies virus, I end up torn to shreds with my liver smeared across my face like linebacker eyeblack, then please do not administer any life saving treatments, vaccine or otherwise.
If I sustain third degree burns over at least 90% of my body (car crash, airplane crash, kitchen mishap), you may save my life as long as I am able to weaned from the ventilator within 30 days and if and only if you promise to attire me like a Mummy, with fresh mummy wrappings applied every morning with little slits for my unblinking eyes. At least until someone figures out the stem cell thing and can make my body grow normal appearing Buckeye Surgeon skin.
If I develop pneumonia after the age of 85, and it gets to the point where the antibiotics are not working, and I am drowning in secretions, failing medical management, and need emergent mechanical ventilation, you may intubate and heavily sedate me. Then extract funds from my retirement account to have my near lifeless body shipped to Oregon where a "Doctor Carraway" will be on hand to inject me with euthanizing agents. I know it seems like a hassle. But I dont want to die by drowning. I think I'd rather light myself on fire.
Let's say I'm ninety. I hobble down my driveway to the mailbox. It's empty again. I look up into the sun and my thoughts wander, or rather they momentarily descend into incoherence. A few minutes elapse during this reverie. Suddenly a pack of vultures alights upon me, pecking away at my limbs and torso like some found carrion on the veldt. Perhaps they are fooled by my decrepit appearance and stillness into thinking I am actually dead. Even if I am brought to the ER with vital signs, I want no heroic measures taken. Morphine and versed is all. One must not fight the law of nature. When the worms and vultures come knocking, one is better off not fighting it.
Imagine I am 82. I have fallen in the bathroom and cannot get up. My head smacked into the toilet basin on the way down. Blood is everywhere. I can see my femur jutting out through the skin of my thigh. Two days elapse. I drift in and out of consciousness. I recall that I have installed a trap door in my bathroom for this exact situation whereby the floor swings downward and I fall into a pool stocked with poorly fed crocodiles. If anyone walks in once the trapdoor mechanism is activated, please do not disturb the reptilian feast.
What about dementia, in general? Well if I'm charmingly demented, can fake my way through encounters with people I've known for years and I am not regularly shitting my pants, then please administer basic life saving maneuvers, as long as the above declarations are followed. If, however, I am one of those obnoxious demented guys----like the ones who moan all day long, who spit at and/or bite the health aides, who tell loved ones to fuck off or go suck on something, who smear their own stool over their faces, then please please activate Extraction Plan C, as detailed in the affixed appendix (i.e. the one involving a mud hut in Hocking Hills, gas powered generator, and long exhaust tubing.)
How about decubitus ulcers? The circumstances that lead to the development of these unsightly open sores usually indicate some degree of generalized decreptitude. The following instructions are to be adhered to without fail: No surgical intern is allowed to swing by my hospital room once a week to roll me over on my side like a rump roast and whittle away at the dead and decaying tissue hanging off my sacrum. If at all possible, I hope that technology at that point would allow me to live a partly amphibious existence, suspended in some sort of flotationary liquid-based apparatus. If not available, then simply do the bare minimum to limit the odor emanating from my backside.
If I am sleeping more than 18 hours a day, do not wake me up for "health-ercize" sessions.
If I want a gin and tonic, do not deny me this last, simple pleasure, even if I have transformed into angry cussing demented guy.
Do not put PRAFO boots on my feet.
I will not tolerate sponge baths from male nurses.
When incapacitated, please keep my feet covered at all times with white tube socks. I am terminally uncomfortable with the appearance of my toes.
In the final days, someone has to check on me every couple of hours to make sure my mouth isn't gaping open while I gaze permanently at something in the left upper quadrant of my visual field. Either pull the covers up over my trap or tug my damn lips closed.
Do not bring young children around me in the following situations: rasping death rattle breathing, unmaskable smells, strained rictal facial expressions, clonic body convulsions.
This declaration may be amended as I deem fit. Please honor my wishes, in good faith, and use this legal document as a guide when my mind and body have inextricably failed me. Thank you.