Health AGEnda

Can Someone Override Your Advance Directive?

Posted in category End of Life Care

30 comments

My uncle, an avid jogger, trained for years with the Road Runners in New York City. He preferred to jog in Manhattan’s Central Park. He knew families of squirrels there, feeding them walnuts when he stopped to rest. He said that one squirrel would come up to him and personally request a meal. He would share updates on the red-tailed hawk known as “Pale Male” that lived on the ledge of a high rise bordering the park. Running and Central Park were my uncle’s two great loves.

A man displays a DNR tattoo

Over the past few years my uncle’s cognition worsened. Slow progression at first was followed by bouts of sharp decline. Early on, my uncle shared his wish not to extend life when he no longer enjoyed quality of life. This informed perspective came from watching his own mother’s deterioration from Alzheimer’s disease. My uncle shared his wishes with the family. He designated a health care proxy to ensure that his wishes would be honored.

As the disease progressed my uncle needed 24-hour home care in his apartment. Our family hired a personal trainer to take him on runs even as he no longer understood how to put on his own gloves. He still loved running. As his needs increased, he moved into assisted living. The enclosed grounds had walking paths and gardens reminiscent of his beloved Central Park.

Sadly, he fell, breaking his hip. The fracture needed to be repaired or he would remain in agonizing pain. However, the surgeon refused to do the surgery unless my uncle rescinded his Do Not Resuscitate (DNR) order.  This brings me to a dirty little secret we aren’t supposed to know about advance directives: providers may pressure patients and families to lift a DNR order. In some cases doctors ignore advance directives altogether. One reason is that DNRs can hurt the physician’s quality metrics. Physicians–surgeons in particular–do not want a patient dying on their table. Quality measures are increasingly being made available to the public. For example, in Pennsylvania you can enter a surgeon’s name to look up their surgical mortality rate.

The Patient Self Determination Act, enacted in 1991, established the right to articulate end-of-life wishes through advance directives. The right to an advance directive has existed for more than 20 years. Yet the federal law lacks the teeth to defend these patient rights. This means it is status quo for surgeons to demand that patients rescind their DNR.

Both the practice and policy realms need to address this flouting of patient autonomy and the intent of the Patient Self Determination Act. There must be a way to protect patients’ rights while easing surgeons’ worries about quality metrics. In the end, my uncle had no real choice. He had the surgery with the DNR removed. Both his hip—and the DNR—are thankfully back in place.

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30 thoughts on “Can Someone Override Your Advance Directive?

  1. Leave it to an all-knowing nurse to explain this to us. But in my admittedly less valuable opinion (just an MD), this is a gross misstatement of the situation. I do not perform surgery, nor am I an anesthesiologist. My understanding has always been that this longstanding and pervasive policy is an ethical issue. Putting a patient under anesthesia for a procedure constitutes a positive intrusion into their own life support mechanisms; the anesthetist, at the behest of the surgeon, assumes the responsibilty for cardiopulmonary function during the procedure. For as long as that state exists, it s outside the physicians’ role to abandon that responsibility. Once the patient has come out of recovery, the DNR/DNI is to my understanding always reinstituted. But what do I know? I am sure it is REALLY all about the big bucks.

    • really, yes you must be a physcian, gods right hand. really you said this about a nurse, who probably has saved you from getting sued many times. Lets talk turkey. a DNR is at the request of the patient. to my understanding once a person is under anesthesia, the next of kin becomes the go to person for decisions, not the Dr. Oh my I have a Durable Health Care Power of Attorney, DNR and Advanced Directive. Who is the Dr to over ride my wishes, or my Federally granted right to mechanical means of life support. You said that the patient is essentially on a life support mechanism under surgery. I do not understand that remark is all your patients flat lining on the table? Lets face it, in the world today, we are made of statistics and law suits. Everybody is C Y A . The PATIENT HAS THE RIGHT AT ANYTIME TO REFUSE MEDICAL AND LIFE SAVING TREATMENT. THAT MEANS TO ME IF HE WANTS THAT TREATMENT TO STOP AT A CERTAIN POINT THAT IS HIS RIGHT.

      • To continue my post I simply mean, an Advanced Directive lets the Dr. know at what point the patient wants no further medical treatment. The issue is ethics. We take oaths to do no harm. When some one flat lines and looses precious oxygen, brain damage will occur. The extint depends on the situation. I have as stated before all three in place, and do not want to be plugged into the machine. Drs’ must act as a moral agent, and abide by the patients wishes. When a woman is pregnant and the baby is c- section, if an emergency happens, DRs’ make choices. Usually, if she has other children, they let the baby die and save mom. Drs’ have incredible dilemas but if the mother says save the baby not her, we ( at our hospital) abide by the mothers wishes, it is her life and her decision.

      • I think that the doctor-bashing needs to stop. I understand that the nurse spends the most time with the patients…probably because they have how many patients to take care of a day?….like 2, 3, 4, 5 maybe? Oh wait, I as a physician have to make he ultimate decision for no less than 30 patients daily in the hospital and that doesn’t include if I am seeing Clinic patients as well. Also, physicians are the ones who have to deal with the consequences of every decision made and everything that the patient endures during treatment whether from nurses, techs, etc….it’s called responsibility. Medicine is an art and not a science. When nurses are perfect I welcome them to take over the hard decisions and assume all the responsibility. Physicians are obsolete anyways since nurses, PAs, anyone who reads WebMD, lawyers, and those with MBAs apparently are better skilled than physicians. So sure it’s all the doctors fault. But when a patient is unable to make decisions and the physician has to assume responsibility once more it is always the doc’s faults and they just want to make money off of treatments and bully patients of course. That’s what we do…it’s all about the numbers as you say. Consider for a second that you are an idiot and don’t know what you’re talking about…I sure have considered it….

      • Tammy, you don’t know the first thing about the situation. You shouldn’t express an opinion about a subject you clearly know absolutely nothing about. Allow me, a nurse frequently at odds with the idiocies of many physicians to educate you on the intelligence of the one you are incorrectly treating like a pompous windbag. Which I believe is actually you in this case, not the doctor. The rescinding of the DNR is for the surgery and the immediate period of recovery after that. DNR is for a “persistent unconscious, terminal or end stage illness” according to the Patient Self Determination Act of 2001. See the following link for an abstract which should be understandable in layman’s terms for you: http://www.ncbi.nlm.nih.gov/pubmed/1588296 . This patient does not have the right to force a doctor to operate with a DNR in place under that laws because he does not meet criteria under this law was he in the end stage? Was he on hospice? Was he persistently vegetative? Obviously he was terminal, but that does not give us the right or need to kill him. Besides, no doctor in his right mind would just sit there and watch a patient die on the operating table halfway through an elective surgery. Not just because of metric either. Good lord you are cynical, Amy. By the way, hip fractures are elective. If a doctor chooses for ANY reason not to do an elective surgery that’s up to them. Its not pressuring the patient, its simply a statement of parameters for the surgery. The patient doesn’t get to refuse a sterile field during surgery either. It may be his right to refuse medical treatment, but he only has the right to care for immediately life threatening conditions or the transfer to a facility which can deliver such care under EMTALA (1986). EMTALA is a Federal mandate for hospitals to stabilize life threatening problems and deliver babies regardless of ability to pay. See http://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/index.html?redirect=/EMTALA. That’s all the care anyone has a RIGHT to. The doctor won’t do the surgery under those idiotic conditions. The doctor doesn’t have to do it. And he or she shouldn’t. I am a nurse and I think Amy’s point of view is skewed and unrealistic and I doubt she has had any experience with surgery or ICU based on the notion that the physician was wrong here. You are unnecessarily condescending to this guy and woefully ignorant of how things work in the surgical setting. Without ventilator and blood pressure maintenance drugs, (AKA LIFE SUPPORT) during surgery, anesthesia drugs would kill every patient every time. You don’t think the anesthesiologist is the highest paid person in the room because he knows which drugs to give to put them down do you? Hell, I am a nurse and I knew that when I graduated and had no experience. He is valuable because he keeps them alive in spite of the drugs which make them unaware of the knife and saw and hammer. They have to have their airway protected and their circulatory system propped up. When surgery is done, the doctor weans the patient off these measures and rescues them from the side effects of anesthesia drugs which are frequently cardiac or respiratory arrest. If unable to recover from the surgery and anesthesia, then they are extubated and the advanced directive is followed. If they code while anesthesia drugs are in them, we work them, if the drugs are out of their system and they code, we let them go if that is their wishes. I have gone to bat for plenty of DNR patients to over ride some dumb intern who was too afraid or ignorant to turn off the ventilator and I have held the hands of wives and children while their loved ones’ (already dead in all but body) heart beat slowed to a flat line on the monitor. I am a patient advocate. And I am the patients advocate when I say you and Amy are absolutely on the wrong side of moral and legal and ethical right on this issue. Having the surgery under these conditions is tantamount to EUTHANASIA.

    • Perhaps the good doctor would do well to LISTEN to the ‘all knowing’ but lowly nurse who has more patient and family contact hours than he will ever experience…
      That said, it must be noted that ‘Do Not Resuscitate’ does NOT mean ‘do not TREAT’. Some of the most pathetic situations that this ‘lowly RN’ has dealt with involved patients who NEEDED to have an advanced directive but who never made one.

      • My dad also had a neurological disorder and broke his hip. He was not yet on hospice but had a DNR/DNI. We were happy to suspend the DNR/DNI for the surgery. Its not a permanent suspension. Its to give the patient a chance of surviving an artificially produced challenge to their cardiac and respiratory system which is expected to return to normal after the surgery and anesthesia clears the patient’s system.

      • I don’t know what backwoods hospital you hail from, or what decade you practiced, Granny, but physicians do not treat us like that anymore. If they are treating you like a “lowly RN” you should avail yourself of the hostile work environment laws. Or just pop one in the eye. Either way, if that’s how you see yourself or allow others to treat you, its sad, but its got no bearing on the argument about the ethics of DNR.

        • I think everyone has taken this way out of context. The first response was very negative and should not have been said and spurred the responses you see above by nurses. The author was simply trying to bring awareness to the ethical dilemma that exists today with families and medical staff. There are many gaps in education on the laws of advance directives. Physicians are sued by families for thing that are out of their control and nurses are not respected by some physicians such as the one above. It is better to put your frustrations to work and help create a clearer law on advanced directives. Both the Physician and Nurses response do nothing positive for our professions.

    • While I find your argument to be correct in all its technical and ethical aspects, it would have been better received by the nurse readers without some of the sarcasm and condescension.

      • I am delighted to see that the topic spurred a dialogue on overriding advance directives. More than that, Eddie, I appreciate your willingness to comment on my language and will be mindful of the feedback. Today is National Healthcare Decisions Day. This a perfect opportunity to remind folks to complete an Advance Directive, encourage their families to do so as well, and continue to press for respect for the decisions we make and document. For more information on National Healthcare Decisions Day go to http://www.nhdd.org.

        • My mother, an 86 yr old alzimers patient who can not talk or walk and in a nursing hope got a uti. While being treated by a doctor in a skilled care nursing home the uti went to renal failure and dehydrated coma. She has a living will and dnr. She was sent to the hospital where a hospital employed nurse signed the consent to treat form as moms legally appointed representative. Mother was revived to brain damage, which according to doctor was to be expected with alzimers. There was no benefit to the patient. Have been told by US Senators office that doctor has legal rights to do this. Hows that for RIGHTS

          • Rick, first and foremost I want to offer my condolences and share in your frustration. I don’t know the details but if the hospital did not have a copy of the DNR on file, I could see the wrong care being provided. A small number of states have developed registries so emergency medical technicians and hospitals can access this kind of information (about treatment preferences at the end of life) no matter where one is treated. You are welcome to share the details with me (amy.berman@jhartfound.org). It should never happen. But again, without details its hard to know what contributed to this terrible outcome. My heart goes out to you and your family — Amy

    • Although I respect your personal and professional opinion, you did not do the medical profession a justice by undermining the opinion of the “all-knowing” nurse in the most condescending way possible, which stripped your otherwise insightful post of any respect or validity. This is where all of these aggressive replies are coming from. Next time you post, try to be more respectful of other integral members of the interdisciplinary team while voicing your 2-cents.

  2. I had the exact same experience! My father, also suffering from advance dementia, fractured his hip and required surgery. The surgeon actually agreed to operate WITH DNR in place but the anesthesiologist refused(head of anesthesia so another anesthesiologist was not an option). We had no choice and the DNR was rescinded. I did follow-up (after surgery) with administration and was told that an ethics committee could have been called to assist with this decision. If anyone else is facing this dilemna, I would suggest asking to speak with the facilities ethics committee.

  3. Editor’s note: This post was included in the March 29, 2012, issue of the Health Wonk Review, hosted by Health Business Blog at http://www.healthbusinessblog.com/2012/03/health-wonk-review-supreme-court-week/.

  4. Ann, thank you for sharing your experience being pushed to rescind a DNR order. It is good to note that the Ethics Committee played the role of the cavalry. Arthur, this suggests that it is not an ethical issue to maintain the DNR. And please do note that I do not see this as a blame issue but rather a need to understand the patient-centered goals of care. In the case of my uncle and Ann’s father, the goal was comfort and quality of life, not quantity of life. Perhaps bodies that establish publically reported surgical quality metrics could remove those opting to keep a DNR out of both the numerator and denominator. It in no way speaks to the clinical skill when one asks the surgeon or anesthesiologist not to revive a patient. Thank you both for your comments.
    Warmly, Amy

  5. Does someone who has chosen a non-course of treatment ever belong in an operating room?

    Will such a person ever have the cognition to rehabilitate and walk again? Probably not. Should they be made comfortable – absolutely. Should this include surgery that includes a risk that they’ll need to be resuscitated?

    Maybe so, if so their guardian needs to recognize that they are valuing their loved ones’ life sufficiently to override a decision they made at an earlier time.

    If you want a medical procedure bad enough to employ a surgeon to go into surgery then I think you need to be willing to let them do what they must to get you out of surgery.

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  8. My Husband had an an operation that left him unable to breathe. His Drs strongly suggested hospice and DNR, we agreed. He went into a 2nd hospital that did procedures and an operation, ignoring his Medical directive, and did not ask me, and had no consent. I believe this only prolonged his suffering, what can I do ?

    • Dear Deborah,
      I am sorry for the anguish that you and your husband experienced. My suggestions are limited to improving the provision of health care. You might consider using your husband’s experience as a teachable moment. Your husband’s health care providers and the hospitals involved won’t understand that they failed you without your detailed feedback. I encourage you to provide it, if you haven’t already. You may wish to meet with the Ethics Committee of the hospital as well so they can address systems issues that may have contributed. One benefit of sharing written feedback or arranging a meeting is the opportunity to hear their perspective. Were there factors you are not aware of? My heart goes out to you and your family, Deborah. I wish for you (and others) the care that fits with your goals and values, care that respects your wishes and supports dignity. We deserve it. And it is our right.
      Warmly,
      Amy

      • Thank You for your response,
        I have notified the hospital, they have admitted they did these things with out my consent, and my husband was too confused to make decisions. No factors I was unaware of, they made choices against his medical directive, and his wishes. I can’t change what happened to him, so I have notified the Medical Board, and local law makers so hopefully, this never happens to anyone else. You are right, it was his right, sadly they choose to ignore his last wishes. Thank you for your kind words, Deborah

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  10. My question was whether the FAMILY had the right to disregard written wishes. My family (not close) are of another religion and would definitely disagree and keep me hooked up against my wishes. This horrifies me. I plan to name someone outside my family as health care advocate–will she be able to prevail?

  11. First, some of the above are confusing a DNR with an Advance Directive. The Advance Directive sets outs a patient’s wishes when the patient has a terminal condition or persistently unconscious. In most states an Advance Directive will trump a DNR. In the case of the DNR, in all cases a DNR is suspended during surgery. The reason is because while in surgery, the physicians, RNs, and staff cannot tell if it is due to the artificial nature the patient is under for surgery or the patient’s underlying condition. This is not a matter of doc vs. nurse. This is the law in most states.

    • Excellent points. It is all true that one lifts a DNR while an artificial airway is in place. It is the law in many states, also true. But when a person crashes on a table, when they code, when their heart stops, there is a decision about whether or not to resuscitate. In some of those same places, the response to the patient’s intent of not being resuscitated is respected.

      This topic is nuanced and the discussion about honoring preferences is important.

      Am very appreciative for the comment.
      Warmly,
      Amy

  12. I have been a respiratory therapist for over 20 years. I plug people into the wall for a living. I have seen countless cases where the patient made his advance directives clear and a DNR/DNI was noted in the medical chart. But after the patient lost the ability to speak for himself, the family rescinded the DNR/DNI status and replaced it with a full code status. Recently, I had to participate in the care of a 98 year old woman whose son rescinded her status. She was placed on life support and died on life support. There are too many cases to even comment on from my perspective. It is something we expect in our ICUs.

    • Dear Sherri,
      Thank you for sharing your recent experience seeing an advance directive over ridden. It’s sad to think our documented wishes could be disregarded. There should be a systems approach that addresses these ethical conundrums and supports the rights of the individual. As it is, the system lacks accountability for such harms.
      Best regards,
      Amy

  13. I am a current RN at a largely geriatric hospital. Unfortunately I have been witness to too many instances where a documented Advanced Directive has been completely ignored by children, siblings and spouses, culminating in feeding tubes placed and ventilator support systems that are clearly negated within the directive. I am very frustrated that these written and witnessed documents; that an individual went to the time, thought and trouble to complete, are ignored at the time when they MOST need adherence to. I am confused as to why the legal community will not take a stand on this issue and make hospitals and physicians abide by them, and accountable when ignored.

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