The Hospital Ignored My Mother's Do Not Resuscitate Order

My mom had a great outlook on life.

She wanted to live fully until her very last breath.

About five years before her death, she was diagnosed with congestive heart failure. Although she was not preparing to die, she was at peace with the fact that it could happen.

When her heart stopped, she would be ready to go. That was how she viewed it.

The most important thing to her was that no one attempt to revive her when it happened.

Every time she went to the hospital, she asked the nurses to place her Do Not Resuscitate order in her medical record. She would even ask for it to be posted on the door of her room.

Had she been able to, she probably would have had it tattooed on her arm.

When someone is living with congestive heart failure, each crisis can feel like another step down a ladder. They may stabilize for a while, but they never fully recover. Their health gradually worsens until the final crisis comes.

We went through a series of these crises with my mom.

Each time she entered the hospital, we had no idea whether she would come home. Eventually, we began assuming she would because she had survived the previous episode.

But when she was admitted in November 2009, the decline was much greater.

We didn’t know it.

On the night of November 15, I called my brother to ask whether I needed to be there. My brother, who is a physician, told me, “No, I think she’s going to be all right. I think it’s just another one of these episodes.”

But it wasn’t all right.

Later that evening, my two older sisters arrived to see her. After sitting with her for a while, they asked whether she would mind if they went downstairs to get something to eat.

Minutes after they left the room, her heart stopped.

She was gone.

She had lived as she wanted, on her own terms, until her final breath.

But hospital staff rushed to her bedside and initiated a full code in an attempt to restart her heart.

They had failed to see the DNR order in her record and did the one thing she had explicitly said she did not want.

Thankfully, my mom was a strong-willed person.

She did not come back.

My family and I felt deeply relieved that she didn’t. But we were also furious with the hospital.

We asked the staff, “What were you thinking? Why did you ignore her explicit DNR order? What happened?”

We quickly learned that the hospital staff were good people. It was, and remains, a good hospital.

The problem was the culture.

That culture said that if someone died during your shift, something had gone wrong. Extending life meant it had been a good day. A patient dying did not.

So when my mother’s heart stopped, the staff went into autopilot. They did not pause to ask what she wanted at the end of her life.

This happens in hospitals everywhere, every day.

Culture is powerful.

To honor the wishes of the people we serve, we have to understand incidents like my mother’s as evidence of a larger cultural problem.

Everyone working in medicine should resolve never to tolerate an incident like this, not even once.

By doing so, we can become the examples our organizations need to change a culture built around extending life at all costs.

We must make the end of life what it should be, what we want it to be, and what the people we serve have told us they want it to be:

A human, healing and sacred experience for individuals and the people who love them.