Wednesday, June 10, 2015

My Personal DNR Order

After putting it off a long time I finally got around to a little detail that has nagged me for some time -- a personal Do Not Resuscitate Order. My wife and I completed our advance directives for medical care some time ago, both of which include a so-called "living will." But those documents are only needed if someone is unable to communicate (coma, stroke, dementia, anesthesia, otherwise). Advance directives appoint one or more agents for medical decision-making should questions arise while we are under medical care.

But there can be an accident or some other life-threatening event when the only medical resources are those responding to a 911 call or a nurse or doctor who might be available. Those people will be trained to immediately begin life-saving CPR and first aid. I know this because I am CPR and First Aid certified myself and have been most of my adult life.  And if I am knocked unconscious and bleeding, I want by all means to have someone stop the bleeding, clear an airway, keep me safe and covered, treat for shock, and do whatever is necessary to keep me from dying. 

However, should my heart stop beating and my breathing stop I am prepared to die. The statistics for cardio-pulmonary resuscitation in a hospital setting are not impressive, and bystander life-saving using CPR are even worse. Moreover, lack of oxygen to the brain damages cognition and memory more than a restored blood supply can repair. If I were younger ten years or more I would (and did) want to take my chances with CPR under emergency conditions. 

Having passed seventy and given the matter a lot of thought I have come to terms with the inevitability of dying. According to the actuarial tables of the Social Security people, I have a life expectancy of thirteen-plus more years. That's pretty good, and I hope to beat it. In fact, every year that we survive we do, in fact, "beat the odds." If I am still alive ten years from now my life expectancy will not have diminished ten years. In fact I will pick up four additional years simply by surviving another decade. As a male aged 81 my life expectancy becomes seven-plus years! That's pretty cool when you think about it. There is an actuarial life expectancy even for centenarians and beyond. As long as there is life, there is hope.
To Dr. H---- or whom it may concern: 
I want a DNR bracelet and/or tag to wear around my neck indicating that in the unlikely event my heart and breathing stop no CPR or intubation will be used to resuscitate me. I realize this is an unusual request and that despite clear instructions to the contrary EMR teams or others trained in CPR, motivated by the best of good intentions, may intervene anyway.

A copy of my advance directive for medical care is in your file, but it’s not practical to carry on my person all the time. A bracelet or tag with my ID and telephone (or other validating contact) is more suitable.

To be clear, I do not want to die. But that is not the same as saying I am not ready to die. As many military and first responders know, being ready to die and wanting to die are not the same and must not be confused.

My reasons for carrying a DNR are easy to explain. At this writing (age 71) I have spent the last twelve years working as a caregiver, mainly with seniors. During five years in a retirement community and seven years as a non-medical caregiver via an agency I have had many assignments and have seen the effects of age and disability in a way that most people never do. When I die I want to be remembered as someone leading a full life, productive and helpful to others. As I now approach the end of the actuarial tables, the longer I live the less likely that outcome will be.

I have seen too many people dying a little at a time, increasingly dependent on others even for the simplest needs. The decline may be physical, cognitive or both. But in all cases the quality of life is compromised a little at a time until the dying person is left in a miserable condition, often for years, waiting, waiting for that final appointment with the Angel of Death. That is a condition I want to prevent, if possible, by deciding now against heroic life-extending measures. 
This is not an appeal for everybody to follow my example. I am a firm believer that end of life and beginning of life issues are among the most private of all human decisions, involving as few others as possible. Making final arrangements we need the input and advice of family, friends, clergy and legal council. But there is no substitute for thoughtful reflection and doing lots of homework. I provide this, my personal journey notes, as a friendly reminder that we all have and share one final appointment with the Angel of Death. 

My decision is influenced in part by what happened to my father following a stroke which incapacitated him for almost a year before he died of another cause. During that time he was not the person I had known as my father. He was not interested in eating and was kept alive by nutrients and hydration via a PEG tube in his stomach. He was in a good skilled nursing environment, well cared for and not in pain. But I want nothing like that to happen to me. If possible I want to be remembered full of vitality, alert and productive to the end.  

I could also cite many examples from my work as a caregiver, but that could be interpreted as a violation of the rules. No matter. There are numerous on-line places with tons of information. I just recently came across a Facebook page for The Caregiver Space. And I am happy to answer any questions in the comments. 

Legal and practical requirements vary from state to state, and even when everything is in order, it is possible that a bystander with the best of good intentions will apply CPR anyway. The same is apt to happen with EMT personnel or others not aware of my decision. To that end I wear a medical alert tag around my neck that says look in my wallet. In my wallet I have a small copy of my DNR order, together with my ID, that of the doctor and a contact phone number. I read once about a doctor, knowing that his DNR might not be readily available, had "Do not resuscitate" tattooed on his chest. 

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