Do Not Rescusitate-Conclusion

Remember what I said about my surgeon yesterday?  Plain talker, not pretentious, good guy?  When you think of the hospitalist think the opposite of those qualities.  This doc gave me the distinct impression that rather than listening to what I was saying he was always thinking of what to say next.

When the hospitalist came in the room he sat in a chair for our initial conversation.  It seemed  rehearsed.  He asked if I wanted extraordinary measures taken should I have a medical emergency.  I said I had all that written down in an advanced directive which I had given the hospital.

“You’re saying the hospital has that on file?”

“Yeah.  My wife gave it to one of the nurses during admission.  She made a copy.”

“Well it’s not part of my file.”

“Yeah, well I gave it to them.”

“I’ll make a point to find it.  So tell me, in a general sense what are your wishes should we encounter the need to resuscitate you?”

“I don’t want anything heroic to happen if there’s no point.”

“I see.”

We talked some more, sort of.  Before he left he asked

“Mr. McClure, how can we help you better?”

“When this leg block wears off and I have to take other meds for pain you could give me morphine instead of hydrocodone.  I’ve had morphine in the past and it worked the best. I have good memories of that family of drugs.”

He laughed.  I had made the same request of my surgeon, each nurse I encountered, and while not laughing at me like this guy, all of them dismissed it. 

“We don’t give out much morphine these days,” the hospitalist said.  “Morphine is old.  There are more effective drugs now.” 

That seemed to be the general consensus.  Morphine was the only bright spot in my operations long ago, and now that was gone.  Also gone however, was much of the pain.  Hydrocodone is now king.

In less than a half hour the nurse, either my own or the nurse in charge, an older woman who looked like she knew her stuff, blew into the room and made straight for my bedside.

“Do you know you have a DNR?  Is that what you want?”

“DNR as in Do Not Resuscitate?”

“Yeah.  The hospitalist ordered it.”

“Generally yeah.  I guess.  I mean if it’s only going to prolong my life…”

“No you don’t get it.   Your chart has a DNR.  If you have an arrhythmia out of the blue, or some freak thing happens that you stop breathing, I can’t help you get over it because you are DNR.  Is that what you want?”

“Well no.  I mean if I’m in god awful shape and dying, you know, and shocking my heart back to life or putting in a feeding tube only lets me live a while longer I don’t want that.  But if as we’re talking here I can’t breathe then, yeah, I’d like you to help me out.”

“That’s what I thought.  I’m going to talk to the doctor.  I’m not sure he knows how you feel.”

My wife came back from the cafeteria about that time.

“Honey, let me see that Five Wishes thing.”

She dug it out of her purse and I started rereading it. 

“I talked to that hospital doc and he’s got me down as not wanting to live if I have some kind of an emergency.”

“What?”

“He marked my chart Do Not Resuscitate.”

“What in the world did you tell him?”

“I told him I didn’t want them knocking themselves out if I was dying.  But apparently a DNR has everyone standing around watching me die today and tomorrow.”

“Well you’d better change that.”

“No kidding.”

It wasn’t twenty minutes before the nurse, with the hospitalist five steps behind her, burst into my room.  She went to one side of my bed, the hospitalist took the other side.  I had the distinct impression they were about to settle an argument.  My wife’s eyes were wide. The nurse started.

“OK Mr. McClure tell (the young pretentious hospital doc) what you told me earlier.”

“Well I may have misunderstood your question, but I’ve read my directive here (held up the Five Wishes paper) and what it begins with, is this statement.  Let me read it to you.

I believe that life is precious and I deserve to be treated with dignity. When the time comes that I am very sick and am not able to speak for myself, I want the following wishes to be respected and followed.

I think that’s where the confusion came in.  I was talking about dying.  Do I look like I’m dying?  Hell, I’m 65 and just had my ankle fixed.  Other than that I’m OK.”

“Mr. McClure, with all due respect, that’s not what you told me.  You told me clearly that in the event that you were dying you did not want hospital staff to take extraordinary measure to save your life.” 

“He’s not saying that,” the nurse said.  The hospitalist gave her a dirty look.  She was challenging his judgment.

“Can I see that paper?”

He took the document from me and began to scan it. 

“I think what you have checked here for options in these scenarios backs up my decision.  There are three choices. 

o   I want to have life support treatment

o   I do not want life support treatment.  If it has been started I want it stopped.

o   I want to have life support treatment if my doctor believes it could help. But I want my doctor to stop giving me life support treatment if it is not helping my health condition or symptoms.

In each of these four cases, you’ve checked “I do not want life-support treatment.  If it has been started I want it stopped.”  That’s what a DNR is.  No life support treatment. That’s what I ordered.”

I had the distinct impression he was trying to save face with the nurse for the decision he made.  Thank God for that nurse.

“You’re missing the point.  This whole thing is built upon me being very sick and close to death.  Do I look very sick and close to death to either of you?  And what about the four cases?  Did you bother to read them?  Give that thing to me.  Here’s the four scenarios it applies to.

§  Close to Death

§  In a coma and not expected to wake up or recover

§  Permanent and severe brain damage and not expected to recover

§  Another condition under which I do not want to be kept alive

Do any of those apply to me now?”

Neither of them answered.

“Well do they?”

“Mr. McClure, we can’t predict the future,” the hospitalist said.

“You don’t have to.  Look at me right now.  Do you know why I’m getting this ankle fixed?  So I can take trips and walk around new places.  So I can golf eighteen holes, with a cart, and not have to ice my leg for six hours and hobble around the house.  So I can walk my daughter down the aisle.  It’s maintenance and repair for Christ’s sake.  I’m not dying.”

They didn’t respond.  I had a cup of melon chunks left over from lunch in a plastic cup with a spoon on my table.

“Are you telling me, that because I’m listed as a DNR, if I took a bite of this fruit and got a chunk of honeydew stuck in my throat and turned purple, neither of you would do the Heimlich on me?”

“Yes,” the nurse said.  “As long as you’re marked DNR.”

The hospitalist chimed in. 

“There are people you know, who believe they have lived a good life and do not wish to continue under any circumstances.  But look Mr. McClure, if you want to change your mind it’s fine with me.  I can change this order and I will.  Just tell me what you want.”

“How about this.  If I look like I’m dying in the next two days, and you can bring me back, do that. Then we’ll discuss what happens again.  And if you can’t talk to me, talk to my wife or my kids.  But I am pretty interested in continuing to live.  Life if pretty good.  I’d like to stay at it.  Hell, with any luck I might even break 80 on the golf course before I actually turn 80.  And I wouldn’t mind turning 80, as long as thing are going well.  So yeah.  Forget whatever I said, bring me back to life, and either me or my family will take it from there.  But I don’t want you making that decision.  Do you understand?  I want my family to decide.  They know me, you don’t, and there you go.”

I wished I had brought my flask.  I needed strong brown alcohol of some kind.  Any kind really .

The rest of my stay was uneventful.  The hospitalist visited me the next day, but his visit was short.  I was released the following day.

As they were taking me out to the Buick to head home, I asked Colleen to find my pocket knife in the backpack.

“What do you want that for?”

“I want to cut these damn plastic bracelets off my arm.”

It’s good to be back in the shack.  Stay out of hospitals if you can.

For information about The Five Wishes, click https://www.agingwithdignity.org/contact

Do Not Resuscitate-1 of 2

I spent a couple of days in the hospital getting my ankle fixed.  Rebuilt in a way.  It was elective surgery to fix an old problem.  I think of it as restoring a vital part of an old tractor; a two cycle John Deere say, or an old Minneapolis Moline.  The details are boring and often constitute the vapid medical discussions of people I’m afraid have nothing better to talk about.  This post is not about what they did to fix my ankle (well maybe a little).  It’s about experiencing and enduring the medical system.  As you may know, or might guess, there are problems.

Submitting yourself to a hospital is, in a word, dehumanizing.  I like my surgeon.  Just a bit younger than me, he speaks plainly and answers my questions.  He told me and showed me what the tests meant, how the procedure was going to work.  If it was just he and I, and he could have come to Ottawa and done his work in the shack, it would have been perfect.  But in order to accomplish this particular procedure both he and I had to comply with policies and protocols.  I hate both policies and protocols, and I don’t think he had much use for them either.  But for him it is the water he swims in.  I’ve been away from it for some time.  Since retiring I forgot, thankfully, how stilted and maddening the environment in a big organization can be.

Before I even got to the hospital I was required to see my regular doctor for a pre-operative health clearance that included blood work, EKG, and a lengthy office visit.  I rarely see my family physician.  In fact, my former regular doc left me, sent me a letter, moved up to administration, and I was assigned to a new young doctor in the clinic.  It matters little.  In reality, when I make appointments I always see a nurse practitioner whom I really like.  She is far better than any male family practice doctor I’ve encountered.  She listens, understands, and takes her time.  And in organizations, it’s the staff that matter.

However, protocol required even her to go through a lengthy checklist of questions about not only my present and past medical history, but my family’s as well.  I don’t know how many times in my life I’ve answered these questions but it’s a big number.  In fact, because I’ve seen her for so long, she knew the answers to most of them before asking.  But she had to ask them anyway, as if they might somehow change.  I answered them politely.  At some point don’t you think the computer system she works on would capture and retain my medical history, the sad problem-based rundown of my body’s failings?  It doesn’t happen.  At that point I could feel the system beginning to focus on my body and not me.  In the end she declared I was surgically good to go, and the deal was on.

I got to the hospital very early in the morning for surgery and after presenting my insurance card, verifying my birth date, and signing a bunch of financial stuff I was outfitted with three vinyl bracelets.  They were a white ID tag with bar codes, a yellow one which proclaimed me a fall risk, and a green one of undetermined meaning.  I was tagged and categorized.  Necessary I suppose if everything went south and they only had the tags to determine who and what the body attached to the bracelets was all about.

“I’m a fall risk?”

“Everybody 65 and older is a fall risk.” 

“I see.”

The put me somewhere else behind a curtain and I changed into the gown.  A nurse came in with a clipboard, smiled, sat down by my gurney and began to ask questions.  It was the very same long list of questions my nurse practitioner had asked a week before.

“You should have a report on all this stuff.  I did this a week ago.”

“That’s for your doctor.  This is for the hospital.”

“Oh.”

“Mr. McClure, we didn’t get a blood test from your doctor so I have to take blood again.”

“I had a blood test a week ago too.  You should have it.  Didn’t you get the results of the other tests?”

“I’ll check again. “ 

She fumbled through some papers on the clipboard. 

“Yep we got other test results but no blood report.  I can call your doctor and ask again but that will only hold things up.  I’m sure they’re not open now.  I can take the blood when I put in your IV or we can wait.  Your choice.”

She clearly didn’t want me to wait.  It would hold everything up. 

“OK, take it again.”

Another woman came into the room.  She also had a clipboard.  She gave me a pen and began rattling off more forms she wanted me to sign.  Instead of automatically signing them I scanned them.  As I signed she asked more questions. 

“Do you have a living will?  Power of attorney?”

My wife took care of that one.  It’s a little grisly but she had mine in her purse.  I was in the hospital after all.  She handed it to the nurse.  We have a relative who taught a course in medical ethics at Marquette University in Milwaukee and recommended a process called “Five Wishes.”  You can do it yourself on the internet.  It takes you through a series of questions and considerations and allows you to choose how you would like to die and who decides what happens before you leave.  I did it years ago when I had a health scare, now so well documented in who knows how many checklists in countless files.  It’s easy and thorough, this Five Wishes thing.  Plain language.  I gave a copy to each of my kids, who along with my wife are authorized to act as agents when and if I reach the end slowly and predictably.  As opposed to say, getting hit by a truck. 

“I’ll make a copy of this,” she said.  She left and returned quickly, giving the paper back to Colleen.

A form giving the surgeon permission to do the work listed the wrong procedure.

“That’s not what he’s doing,” I said.

“Are you sure?”

“Uh yeah.  Very sure.  That’s what he originally intended to do but he changed his mind after an MRI.”

“Well I’m sure he’ll perform the procedure you discussed.”

“I imagine so, but I’m not signing it until it’s right.”

She immediately stopped talking to me and turned the conversation to the other nurse, who had moved on to some other part of the prep work.

“When is he scheduled?”

“He’s (my surgeon’s name) first.”

“And is he getting a nerve block?”

“Yes.”

“Well that’s going to be a problem.  The anesthesiologist can’t put the block in until this is signed, and this could hold up the surgery, and (my surgeon) won’t like that at all.”

“And he won’t sign it?”

I was right there between them.  I’d been listening to their conversation as if I was watching a game of ping pong.  I felt like raising my hand but didn’t. They continued to talk without acknowledging me.

“No.  I can’t say as I blame him.  It is the wrong procedure after all.”

“Well you’re going to have to find (my surgeon).” 

“I’m not even sure he’s here yet.”

With that the nurse left in something of a huff, ripping open the curtain and sliding it back with gusto.  If it had been a door she would have slammed it.

Finally the first nurse spoke to me, or maybe to herself.

“This isn’t good.”

They moved me through the process anyway.  I was wheeled to something of a staging area where others were lined up in a holding pattern.  For all I know we each took a number, like when you renew your driver’s license.  They did more things to me, hooked me up to monitors, put sticky things on me and attached wires to them.  A young doc with a big cart came in.  As he began to take equipment out of his cart he spoke without looking at me.

“I’m here to do a nerve block prior to your ankle procedure.”

Before I could respond a nurse beside me said

“He hasn’t signed off on the procedure.  It’s listed incorrectly.  We’re trying to get (my surgeon) here to fix it.”

The young doc looked at her with disgust. 

“How long is that going to take?”

“We don’t know.  We’re trying to get (my surgeon) here right now but we’re not sure he’s available.”

“I’m busy as hell this morning.  If he’s not here quick I’m going on to my next patient.”

“Well this is (my surgeon’s) first patient and he’s not going to be pleased if that ankle is not numb and ready to go.”

The doc seemed to weigh this and gain a bit of patience from it.  About that time my surgeon strolled up.  He’s a tall guy.  Nice smile.  He shook my hand and looked right at me.

“What’s the problem Dave?”

“That form isn’t right.  It lists the wrong procedure.”

A nurse handed it to him sheepishly.  He looked at the filled in blank at the top.

“Yeah it sure is.  I’m sorry that happened.  That’s what we were going to do when we first scheduled this date.  Either my office or the hospital didn’t make the change.  I’m sorry about that.”

He was the first to acknowledge any fault or offer an apology.

“How about to speed things up you cross that out, write in the right thing, and we’ll both initial it?” 

I used to do that on state contracts.  I was trying to be helpful.  I felt guilty for holding everyone up.

“Nope the hospital won’t allow it.  I’ve tried before.  We’ve got to get a fresh form.”

The young doc there to numb my leg let out an audible sigh.  My surgeon gave him a look.  A nurse joined him in the look.  It seemed to cool his jets a little.  Then a young nurse came running, actually running, with a piece of paper, my surgeon and I both signed it, he drew a big blue arrow on my left leg, the doc with the block did his thing, and they wheeled me into a very cold room, where they transferred me to another table.  The anesthesiologist told me he was going to administer the sedative, and as I scanned the room looking for power tools I conked out.

Soon after (or so it seemed. It was actually four hours) I woke up in a private room and felt pretty good, unlike my experience when they worked on the same leg in the late 70’s and early 80’s.  My leg, from the knee down, might as well have been a block of wood.  I could neither feel or move my toes.  Pain management has come a long way I have to admit.  There were round bottles of medicine lying in the bed beside me feeding some magic liquid drug through through thin wires which drenched the nerves in my calf and kept my ankle numb.  They stayed that way till the day I was released.  Pretty amazing.  On top of that I took nothing else, not even a Tylenol.  My surgeon came in, told me the outcome of the procedure, and showed me X-rays.

“Wow those look like deck screws.”

“They are a lot like deck screws only stainless steel and a lot more expensive.”

“You went in at an angle.”

“Yeah those angles are important.”

We talked some more.  There is an element of geometry and carpentry to the kind of surgery I had.  Having built the shack, and trying to find a comparison I was familiar with, I related what he did to secure my ankle to my tibia as toenailing a rafter to the top plate of a wall.  He agreed.  Good guy.  Regular talker.  Not pretentious.

The rest of my stay was fairly uneventful.  The food was good, the Cubs were on TV, the staff were nice, and I felt little or no pain.  There was the usual parade of people with various job titles coming in and out of my room: nurse, phlebotomist, a woman who explains the menu and writes it down for you, candy striper, care aide, housekeeper, chaplain, physical therapist, my surgeon, the hospitalist.  The only one I really cared to see was my surgeon.  And while we’re here talking about hospitals, couldn’t they expand some job descriptions and eliminate some of those people?  Good god, it’s an army.

I have to say each of the staff were friendly and competent, except for the hospitalist, who ironically probably was paid the most.  I had heard of this newly created role but never met a doctor carrying it out.  As I understand it a hospitalist is the doctor for everyone in the hospital regardless of their problem.  When nurses have a problem they call the hospitalist not your attending physician, in my case my surgeon.  The hospitalist sees you every day.  Looks at your chart.  There is no way one doc in a big hospital can have a working knowledge of all the medical conditions and treatments that are contained in all those rooms on any given day.  I’m thinking he’s the ultimate generalist, keeps the specialists from getting too many calls, and knows a lot about the rules.  I bet somewhere he’s heavily involved in meetings about outcomes.  This hospitalist, a young doc with a cool demeanor asked this question each day.  It was his mantra I think.

“How can we help you better?”