While seated in the waiting room of a Florida outpatient surgery center, an 82-year-old patient received a nasty surprise. The receptionist asked him to sign a form stipulating that the facility would disregard his properly executed DNR [do-not-resuscitate] order.
Specifically, the form stated that the center would ignore his end-of-life wishes “regardless of the contents of any advance directives/living wills.” The patient was angry and confused.
There’s a business rationale for health care facilities to proclaim their indifference to a patient’s wishes. By keeping people alive at all cost, they avoid potential liability for a mishap before, during or after a medical procedure.
But are they allowed to ask a patient awaiting surgery to sign such a form?
“It is legal but it may not be ethical,” said Craig Klugman, a professor of bioethics at DePaul University in Chicago. “It is done out of fear of harming patients and the liability.”
He notes that several medical associations have concluded that asking patients to sign blanket DNR overrides is not appropriate. Instead, the provider should confer with the patient beforehand and hash out a plan if things go awry.
In practice, however, such conversations rarely occur. In the run-up to surgery, harried providers may lack the time or inclination to raise this sensitive issue. And patients might assume that as long as they’ve completed their advance directives and their doctor has signed their DNR order, there’s nothing further to discuss.
There’s an understandable medical reason why some facilities disregard DNRs. Say a procedure involves anesthesia and temporary cardiac abnormalities or other serious problems arise. Anesthesiologists and surgeons can in many cases “pretty easily reverse” such adverse events, Klugman says, thus bringing you back to life before you know it.
“You might have an interaction with the anesthesia drug,” he said. “It can have nothing to do with your underlying disease,” and resuscitating you poses a manageable risk. So it’s no wonder facilities want you to acknowledge in advance that they can intervene in such instances.
Always ask ahead of time if a hospital, outpatient surgical center or other provider will honor your DNR order. Know their policy in advance so that you’re not caught off guard when they ask you to sign something just before they wheel you into the operating room.
“You have to be willing to negotiate,” Klugman said. “When I’m handed an informed consent form, I cross things out and add things in,” such as limiting the institution’s ability to share his medical information with third parties without his permission.
It’s also important to understand what documents you need to convey your end-of-life wishes. Laws and protocols vary by state.
Terms such as “advance directive,” “living will” and “health care power of attorney” can have subtle differences depending on where you live. In addition, about two-thirds of states have some version of a “POLST” form that indicates what medical treatments you want (or don’t want) in an emergency, Klugman says. In some states, physicians and other providers must honor a valid advance directive or face disciplinary action.
Because you cannot anticipate every conceivable scenario when you might get resuscitated or receive life-altering care, think ahead. Write an expansive letter describing under what conditions you want to be kept alive (to play with your grandkids?, eat and drink on your own?, cheer your favorite sports team? etc.).
Use the letter as an opportunity to share your values and end-of-life philosophy. For instance, consider whether you prioritize pain management over mental clarity (or vice versa) if battling a major illness. Sign and date the letter and share it with your family, medical providers and anyone else involved in your care.
“Be as clear as you can be with your written documents and with your loved ones so that your health care agent can express your wishes on your behalf,” said Robyn Shapiro, an attorney and founder of the Health Sciences Law Group in Fox Point, Wis. “Be clear with your doctor as well.”
An often-overlooked step involves completing a psychiatric advance directive, especially if you have a mental illness. Otherwise, a crisis can leave you dependent on others to make life-or-death decisions for you.
“A psychiatric advance directive can be a different form or part of standard advance directives,” Shapiro said. “If you have a history of mental illness, you can say if you want a loved one to enter you in a clinical [drug] trial or get electroshock therapy.”
