LIVING WILL AND DNR

   We often talk about the 'living will '. The hospitals are required to ask every patient that comes to hospital if they have 'living will ' . The lawyers also do living will as part of estate planning . But no one talks about DNR. Many years ago I read an article written in  a medical gernal by a Harvard doctor (not medical doctor ) . It criticised medical community for not 'honoring 'her mother's 'living will ' and how she had to go through suffering . I was shocked that this Harvard professor was not aware of the difference between the meaning of living and the "true' DNR . Unfortunately this confusion is very common and it leads to more problems than help medical community .
    The living will states that "if my condition is determined to be terminal -----". So determines that the condition is terminal or not ? In the article that was written by the above mentioned professor, her mother was admitted to the hospital with the living will and in the middle of the night had a stroke . She was not breathing well , so the doctors decided to put her on respirator. This was done as a emergency decision in the middle of the night . The living will stated that she did not want to be revived ,if the condition was determined to be terminal . There was no way to know at that time in the middle of the time to state confidently that there was no way that she was going to survive or die .So the doctors had to make quick decision and they decided to put her on the respirator . If she would have recovered from the stroke then the decision would be applaud to be great , but when she did not improve then the decision was "wrong " and did not "respect her wishes " . per the author. This reminded me of one of the patients that I had seen .
    I was called in to see this patient .He was admitted to Intensive care unit . He was brought to ER with decrease level of consciousness.He was not breathing good , so was put on the respirator .When I saw him in the ICU, the nurse told that his wife was there , and was very mad .I saw him ,he looked OK and everything looked OK .I was not too sure as to why the wife was mad . I did not know exactly what made him sick . But he looked to be getting better . I asked her many questions ,and got the history . Then I came to know why she was mad .She had brought with her ,his living will 'Her point was that he had living will and the doctors in ER still put him on respirator . She was so mad that she told me that she would be 'suing'the doctors and the hospital . I explained her the situation and told her that he was doing quite well and I expected him to be off the respirator in next 24 hours . He was quite obese male , though young and most likely had 'sleep apnea ' . He also had what is called as 'obesity hypoventalation syndrome . ' This in past was also called Pickwick  syndrome , based on a character from a novel written by Charles Dickens . In this condition patients do not respond to carbon dioxide retention . Normally we have to main stimuli (to our respiratory centers )to breath , One is lack of oxygen and second is build up of carbon dioxide . (there are other stimuli too , but these are main ones in day to day life . )So these patients are very sensitive to sedatives and narcotics . I was not too sure what might have have happened, but my thinking was that he stopped breathing when he was given oxygen , which took away his stimulus to breath as he did not respond to build up of carbon dioxide . Anyway he did well and was taken off the respirator . He was discharged on 3 rd day . After he was taken off the respirator , I did call his wife and asked as to how she felt NOW , about the decision made by the ER doctors in spite of his living will . She was off course very happy .
     The living will is not as great a paper as it is made to be . It does convey the patients thought process about life in general . But one wants to be not put on any artificial life support under any condition , then he or she should consider DNR. . So it is not left to the doctor or paramedic or to the family members, who at times are left with guilt feeling . This is so important in patients who are very old or have end stage disease, like cancer or very bad lungs or heart or have dementia , in short quality of life is very poor .