When is DNR not DNR?

Montparnasse Cemetery viewed from Montparnasse Tower. Copyright 2013 Daniel Ginsberg
Montparnasse Cemetery viewed from Montparnasse Tower. Copyright 2013 Daniel Ginsberg

Patients are often encouraged to make wishes known with a living will or other instrument. If someone says they would not want resuscitation if their heart stopped, they are said to be DNR, as in Do Not Resuscitate, or more accurately DNAR, Do Not Attempt Resuscitation. Success rates one month after out of hospital cardiac arrests when CPR is performed are only about 4.9% to 9.2%.

In Washington State per a directive it often say,

“(a) If at any time I should be diagnosed in writing to be in a terminal condition by the attending physician, or in a permanent unconscious condition by two physicians, and where the application of life-sustaining treatment would serve only to artificially prolong the process of my dying, I direct that such treatment be withheld or withdrawn, and that I be permitted to die naturally. I understand by using this form that a terminal condition means an incurable and irreversible condition caused by injury, disease, or illness, that would within reasonable medical judgment cause death within a reasonable period of time in accordance with accepted medical standards, and where the application of life-sustaining treatment would serve only to prolong the process of dying. I further understand in using this form that a permanent unconscious condition means an incurable and irreversible condition in which I am medically assessed within reasonable medical judgment as having no reasonable probability of recovery from an irreversible coma or a persistent vegetative state.”

For many patients this is reasonable, but not for all. No one lives forever, but even a generally healthy 98-year-old does not have a terminal condition. Many of my older patients tell me they are DNR, but most are surprised when I tell them their health care directive says they would want to have CPR and get shocked with a defibrillator if their heart stopped, as they do not have a terminal condition.

I think this is probably a failure of lawyers drawing up the health care directive to modify the language to what makes sense for their clients. I’m not a lawyer, but they might add something like:

(b) If I attain the age of 80-years-old, then I do not want to have my life artificially prolonged, other than using medications, including intravenous medications, and oxygen. An exception is that if I’m undergoing a procedure and develop a cardiac rhythm not compatible with life, then I would approve of an immediate attempt at shocking my heart back into rhythm if the physician deems there is a reasonable chance of success.

Just because a lawyer inserts boilerplate language, does not mean it cannot be changed.

FMLA Paperwork

I’m often asked to fill out FMLA paperwork, formally known as Certification of Health Care Provider for Employee’s Serious Health Condition (Family and Medical Leave Act). This is either because my patient is ill and they or a family member need to take time off work, or because my patient needs to take time off to care for a family member. Employers want the form as proof that the time taken off is legitimate, even though it is not paid time off.

The four page form is onerous to fill out. If you read the fine print you can see that the Department of Labor estimated it would take 20 minutes to fill out. That’s more time than I get to see a complex medical patient, and at most we charge $25, and often don’t get paid at all. It may be a service to patients, but most of the information requested is not needed, and is not the employer’s business. This task usually falls to primary care physicians. If it’s something we need to do, it should be as simple as possible and not waste our time filling out irrelevant information.

Below is a letter I sent as a suggestion to simplify the form to a single page (formatting of the form altered a little for web display). It has been over two years without a response. Continue reading “FMLA Paperwork”