My would-have-been husband got severe covid in mid Feb. Damage was extensive, so they put him under medically induced coma. End of July will be 4 months in that state.
He's on ECMO, ventilator and dialysis. I don't have information on exact kind of life support. He's never awakened but he can hear but not respond (what does it mean?). Seems like it depends on the level of sedation when reduced to a state where patients could respond. But, all his family got covid and they couldn't visit, so it could be lack of interaction with familiar voices and stories.
He had no stroke or cardiac arrest. But, there's a chance of multiple organ failure. Or, that the same has already happened. If his DNR is just about CPR, then it's in his interest only.
Now, his DNR is dated on 31st August. I think, that when he drew his will, he thought a life support of 5 months is long enough in old age and is better to die than get further life support. But, he just turned 29 and next month they will pull out the plugs.
Can such a DNR be challenged or appealed against? His sister who also has covid, appealed against it.
But, has anyone on here or anyone you know had success in moving a date ahead which was concluded from the will of a patient when drawn in full consciousness and understanding?
Does it not amount to unintentional suicide cum murder? How will doctors do this when they know his heart is beating and he might survive more than not?
PS- I'm a lawyer from a different country but my head is spinning. The case is of New York.
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DivSin
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The information below pertains to New York State laws.
What is a do-not-resuscitate order?
A do-not-resuscitate (DNR) order in the patient's medical chart instructs the medical staff not to try to revive the patient if the patient’s heart stops. This means physicians, nurses and others will not initiate such emergency procedures as external chest compression, electric shock, injection of medication into the heart or open chest heart massage.
It doesn’t mean that ongoing treatment will be withdrawn.
Unfortunately a term often applied, but in this instance carries weight.
A DNR is a patient request that helps guide a medical team in differing scenarios.
Assume a patient has a DNR in place
Patient "A" is at home and suffers a "heart attack" - I use inverted commas as the term "heart attack" is an interchangeable descriptor of a condition used by non medical people, the public in general.
In one instance it could be used to describe a Myocardial Infarction or Cardiac Arrest.
So patient "A" suffers a MI at home, paramedics arrive at the home, and attempt to resuscitate the patient either via chest compression or defibrillator.
Patient arrives at hospital and the medical team (knowing the patient has a DNR) will attempt to resuscitate the patient if the outcome prognosis is good.
Patient "B" sufferers cardiac arrest at home. Patient arrives at the hospital 10 minutes later. Prognosis is bad and the only option to resuscitate is an emergency thoracotomy (95% mortality rate). Medical team elects not to resuscitate.
Patient "C" is already an in-patient, sufferrs cardiac arrest. But outcome and prognosis for good recovery is high. The team will attempt to resuscitate.
Patient "D", also an in-patient suffers cardiac arrest. The patient has a number of other conditions, prognosis is bad - team elects not to resuscitate.
In all instances the medical team considers information available to them along with prognosis in taking a decision.
A DNR is not merely an instruction to allow death when appropriate intervention can in fact save the patient.
But huge consideration is given to quality of life, post resuscitation.
A DRN is seldom read in isolation while ignoring prevailing condition of health.
A DNR is typically drawn up by people to prevent them being resuscitated only for them to survive in a vegetative state reliant on external life support, or to survive but to be left with almost no quality of life for their remaining days.
Now let's consider patient "E".
Patient "E" has a number of medical conditions. The prognosis is bad.
However, this patient has not suffered some event (yet) requiring resuscitation.
This patient is only alive as a result of secondary life support systems - which may include mechanical ventilation, ECMO etc.
The medical team may decide to withdraw life support.
This is not a decision taken lightly, and results out of a unified decision of the medical team.
Extensive consultation takes place with the family during this process.
Some form of time frame is often put in place in the hope that some indicator of improvement occurs.
Here in South Africa, the legal system is based on Roman / Dutch law. Although the country lurches from one political crisis to the next, the legal system within the upper courts (appeal and constitutional) is robust and sound.
There has not been a single instance where the courts have ruled a medical team be compelled to continue providing secondary life support where there is no possibility of survival without it.
In short, the patient is kept alive in a vegetative state by machines - in other words, zero quality of life.
I've done quite a bit of research on this and found the similar position is taken by British courts. The USA system may differ, but I somehow doubt it.
There are two primary factors that underpin reasoning :
1) the courts have no jurisdiction to compel doctors to commence any course of treatment they are unwilling, unable or unqualified to embark on.
2) If the courts were to make such a ruling, the courts would simultaneously have to provide the means to do so, as will as issues clinical directives.
It's a very tricky situation, which is why a time frame is often placed upon the withdrawl of life support.
This time frame allows the family of patients opportunity to obtain further external medical opinion.
All the above aside, medical teams generally continue to try provide life support, or even attempt other medical interventions while consulting with family.
Having read a number of case histories (legal), I gain the impression legal intervention has the potential to be counter productive in that it often sets a date on finality (legal team representing medical team may often request a date be placed on the withdrawl of medical support and a move to palliative care).
I get a sense being a lawyer you intrinsically have the urge to advocate on behalf of your loved one via the legal system in your country if you feel "hemmed in" and without options.
Tread carefully, and do plenty of case research before contemplating any legal challenge.
Rather bring in external medical opinion, or even patient transfer to a different facility if that is possible.
Sometimes patients defy the odds, they just need additional time - there are many instances of that on this very forum.
Wow! I have almost never seen any elaborate answer as yours. It's covered everything it could and should. I have asked for a copy of DNR but technically, I am an outsider so I won't have access to it. But, i'm trying to get access to it. His family has already challenged it. But, as much as I understand law of my land, I will never be able to appeal against it because indian courts will follow indian laws. Appeal or challenge or stay are only available in instances where family members appointed by the patient to decide have filed those.I have studied law but I cannot advocate because I have a business which prevents me to practice. I have to close business if I have to practice because then I need a license.
Since, his family has challenged it already, they have the intention same as mine, pertinent knowledge, a team of competent attorneys and most importantly, resources to go ahead. I've been writing to his sister who alongside her family also has covid but she'd already challenged it. But, the case is pending in the court.
I'm still not sure if the particular DNR means discouraging invasive or non invasive attempts to resuscitate in the event of myocardial infarction or an arrest in case of poor prognosis orbit altogether means passive euthanasia, which is the fundamental cause of fear in the case.
The patient is young, on ecmo and it already makes sense that pressing the chest area might only inflict further damage to his failing lungs.
But, the real problem is denial of giving more time to him and pulling out plugs because there's a fixed timeline decided by the patient himself on a date before the virus was unleashed to wreak havoc on humanity.
An unpredictable scenario where the virus has different impacts on all individuals, not just one strain acting differently but different mutated strains to follow up with and understand as yet.
I'd want to further the date indefinitely, because the infection rate is receding really quickly and America has achieved herd immunity and there aren't enough patients fighting for their lives who'd need an empty bed or ventilator or ecmo anymore and on ground that the patient us young, fit and has zero comorbities.
If it's simply as it seems a Do not attempt to resuscitate because the post resuscitation quality of life will be adversely affected and the patient wishes to die with all respect and painlessly, then I accept it because it'd be a decision of individual, equivalent to fundamental right to die respectfully in my country.
Here no authority can override it otherwise in an exceptional case where medical team doesn't feel in the lines of the supposed order.
So, I can't decide if it's wise to just stand against it unless I know it. But, actually will the courts have authority to override an individual's wish to die respectfully and painlessly in their jurisdiction.
A quick bit of info I have given here before, but is good to understand.Firstly, I'm not a doctor, but a perfusionist - we control the "heart-lung machine" during certain cardiac surgeries, lung transplants - and the ECMO circuit. Always refer back to the medical team treating the patient.
Some patients require mechanical ventilation, some move from ventilation to ECMO. Others do not go on ventilation, but straight to ECMO.
The ECMO circuit replaces heart and lung function, whereas ventilation still requires the lungs to oxygenate blood.
ECMO allows the lungs to "rest and recover, as the ECMO circuit delivers oxygenated blood to the body.
ECMO is resource intensive - in all countries, and its availability is very limited. Doctors have to select who potential ECMO candidates may be. This decision is largely outcome based.
The fact that this patient was selected is generally a good sign.
The DNR aspect here is a little puzzling. Resuscitation is a mechanism by which to both "restart" heart function and simultaneously (in the case of chest compression) maintain blood flow through heart to lungs, and on to other organs.
The ECMO circuit is already performing this function.
I suspect (or am really guessing), the patient may have other organ damage, or possibly heart damage.
The ECMO circuit can temporarily replace heart and lung function up to as much as 2 to 3 months, but at some point the patient's heart and lungs need to resume their function.
This could be an instance where the medical team feel there is nothing more they can do for the patient and taking him off ECMO will result in cardiac arrest - hence the focus on the DNR.
These are some of the horrible decisions doctors have to make.
There may be other patients who could benefit from ECMO, but all equipment is being utilised by patients who have little chance of survival.
The DNR itself, has to be drawn up and signed when the patient is of sound mind and fully understands it's implications.
Quite often these are drawn up and signed when patients are under significant stress and mental duress.
The question remains - was the patient of sound mind at the time of signing a DNR, if not, the DNR is then invalid.
Ideally there should be a witness to the signing who would be able to verify the patient was of sound mind at the time, and his judgement was not impaired in any way.
You are going through a terrible time at the moment, as well as the family members.
Although difficult, everyone needs to try stay focused and exersize restraint. The last thing you need is to alienate the medical team.
Offer honey instead of vinegar, but at the same time ask questions and probe options.
Funds spent on legal fees would probably be better spent on transfer to a different facility - if possible.
Many patients are transferred between hospitals using mobile ECMO units.
Thank you again for your reply. I will come back to read from it again and again as it's coming from an expert.
Ummm...unfortunately, I can't claim that I understood everything precisely but i'm trying to address few things that may give more insight.I have asked the PR team of his company in my contact twice and they have replied in yes his heart is beating on its own. But, there's a suspicious line in his reports which probably they are hiding from me as well, something like doctors fear multiple organ failure. He's on dialysis, that's confirmed.
He can hear but not respond, that's also been told to me. He never woke up from induced coma when they tried weaning off. I don't know if he got agitated or not. So, one critical care doctor I am talking to, suspects there's some brain damage.
It's also confirmed that he didn't go into cardiac arrest or stroke in this period.
Other concern you have is, about how DNR was drawn. It wasn't seemingly drawn within this ICU stay. He's gotten his will drawn and it's 'derived' from there. I kinda find it difficult to understand how a DNR derived from such a will of pulling out plugs after 5 months of ever going into such a situation be considered valid because at the time of writing will, this virus wasn't present so it must be automatically held invalid for supervening impossibility and unpredictability if the medical team treating him has a separate view. Plus, if prognosis is poor why would they keep him going for even 5 months?
A will would not be this comprehensive and precise but more vague to result into a passive euthanasia or is it just me thinking over much.
Also, there's something contradictory. If he drew such a detailed will, he'd be appointing a kin to take a decision if he's not capable of understanding and making decisions. Since he never woke up, it must have been a kin signing DNR in hopelessness but his own sister has challenged it in court???
Thank you very much for writing down your comprehensive answer. I'll read it again a few times to assimilate a few points that seem worth considering and understanding.
Hi! Sorry, not much. Just that he was on echmo and dialysis and not awake fully. His sister had challenged it in court which is pending. Like, two weeks back.So distressed!
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