"DNR" is hospital shorthand for "Do Not Resuscitate." It is an order entered into a patient's chart indicating that if the patient stops breathing, or if his heart stops, no effort is to be made to revive him.
Withholding lifesaving treatment can be an ethically thorny issue, especially if the patient is unconscious or not in his right mind and cannot request it personally, and/or has not made his wishes known in advance in writing, in an advance medical directive or durable power of attorney.
(Uncharacteristically, I kept my mouth shut during the entire Terri Schiavo kerfuffle, blog-wise, except for the one post I just linked, urging everyone to make their wishes known in writing. Do it. Do it now.)
When a lucid, coherent patient requests DNR status, however, virtually all hospitals will honor this request, and in fact have a protocol to follow for ensuring that the patient's wishes are carried out.
At my father's request, a DNR order was entered into his chart last night, and a "no-code" (Code Blue being hospital jargon for an emergency resuscitation effort) bracelet was affixed to his wrist.
The reason is simple. While my father's ongoing biological processes might be prolonged almost indefinitely, he no longer has anything resembling a "life" of any quality. And he's quite ready for it to be over. In fact, while affirming his DNR request after demonstrating his mental competence, he said, rather plaintively, "If there's anything that can be done to hurry the process along, let's do that too." (There isn't, of course, other than completely refusing further care, including food and water. Not in North Carolina, anyway.)
The laundry list of what's currently wrong with him is daunting. He's been paralyzed for almost 40 years, which has its own attendant set of health problems. But right now:
He has antibiotic-resistant pneumonia, which has thwarted treatment by even the Biggest of the Big Guns, the latest and greatest "antibiotics of last resort" like Vancomycin.
The fluid in his lungs, complicated by a non-trivial case of emphysema, leaves him periodically gasping for breath like a beached fish, even with supplemental oxygen.
More troubling are the decubitus ulcers, or pressure sores, which started out as discrete spots on his back near the base of his spine and on his right ankle; the spots on his back and hips have merged into one solid mass of rotting, weeping tissue, and his right leg from the knee to the ankle is open down to the bone.
They are a constant source of continued infection and sepsis, and have resisted all efforts to treat them; the only thing that would keep the one on his leg from spreading further would be amputation, and given his debilitated physical state it is unlikely in the extreme that he would survive such an operation.
Complications from pressure sores ultimately killed Christopher Reeve, and are a constant problem with paraplegics and quadriplegics. My father has dealt with them on and off for years now, but this last bout has finally gotten completely out of control, and as a reservoir for bacterial infection and sepsis they just about cannot be beat.
Modern medicine has done a lot for my Dad. It's kept him alive long past the life expectancy for a paraplegic injured in the late 1960s.
But his body just doesn't have the reserves to keep fighting, and so now the objective is to keep him as comfortable as possible, and with any luck to bring him back home and let him die with his family around him, rather than a bunch of strangers in a hospital or nursing home.
To that end, once he is discharged from this hospital stay, we will be engaging the services of the local Hospice and bringing him back home.
I have had many lucid, coherent conversations with my father since flying to North Carolina on Friday night. But even that is starting to slip away from him; he is existing on several planes of reality at the same time, it seems.
He passes, and continues to pass, the quick-and-dirty test for mental competency, being oriented as to person, place and time (in other words, he knows who he is, where he is, and the day of the week and roughly the time of day); he responds appropriately to direct questions and is capable of carrying on an intelligent conversation without prompting.
This morning he had a perfectly lucid conversation with his doctor, and he and I watched CBS Sunday Morning together, and Face The Nation, and he commented on some of the stories; he's looking forward to a NASCAR race this afternoon.
As the day wears on, however, or if he is tired out from an activity that requires physical exertion (like holding himself in place rolled over on his side while they change his dressings), he starts, well, having extended conversations with People Who Aren't There.
It sounded, at first, like a nonsense monologue, but on careful listening I realized that what I was hearing was one side of a conversation, the other side of which is occurring only in my father's increasingly cross-wired brain. Sometimes, he seems to be having an argument ("No! I said no, dammit, and I meant no!") and at other times he seems puzzled or even amused. He also says things that parse correctly as perfectly well-formed English sentences but don't really make much sense, as when he told me that he had a multi-million-dollar idea for a new and improved outhouse, though given his sense of humor this may well have been his somewhat muddled idea of a joke.
People of a spiritual bent have suggested to me that Dad may already have one foot in the Afterlife, and I guess that's possible. For all I know, he's arguing with his own father, or someone else who has gone on before.
For now, I am treasuring the moments of lucidity that remain, planning to make his end-of-life care as comfortable as possible, and saying my thank-yous and goodbyes.
I really appreciate the e-mails and offers of support that I've received from y'all. Thanks so much. This is a hard time for all of us.
When the going gets weird, the weird turn pro. - Hunter S. Thompson
07 August 2005
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