Volume 5, Issue 2- April 2002

Do Not Resuscitate Orders

Reprinted with permission from Slate magazine. ©SLATE/Distributed by United Feature Syndicate, Inc. Originally published May 22, 2001.

I was working out on the treadmill in the firehouse when the bell went off. I jumped into my boots and turnout pants, toweling off as I headed to the rig. We were dispatched to an address I recognized but couldn't quite place. Pulling up on scene I remembered that we had been there the week before for a man with terminal lung cancer who was having severe shortness of breath. I had been able to hear the fluid gurgling in his lungs without my stethoscope; he had been blue in the lips and unable to speak more than two words at a time. This time he was lying in a freshly made bed, pulseless and not breathing. He had died peacefully, surrounded by family members who called 911 because they realized all of a sudden that they had a dead body in the bedroom and no idea what to do with it. The family produced a "Do Not Resuscitate" order which specified that the man did not want any lifesaving measures taken. Unfortunately the DNR had never been signed, and since the patient had no signs of rigor mortis we were obligated by protocol to work him up. I hated to do it—this was a good death as far as deaths go and the family didn't need to see the things we were about to put this dead man through.

CPR is an absolutely brutal procedure and nothing like they teach you with those nice little resuscitation dolls that the Red Cross has. It's also quite strenuous work to do it right. Especially with old people, chest compressions tend to break ribs. You place your hands on the sternum just right, lean in heavily, and feel the crack-crack-crack as you push down. After the first few minutes of compression the chest is a loose, shifting mess. Add to that the fact that patients invariably vomit as you're trying to ventilate them, and the glory of lifesaving fades out pretty quickly. I've often thought that I could make my fortune by marketing a true-to-life resuscitation doll that spews bile when the student leans over to blow air in. Well, maybe just a very small fortune.

The worst thing about CPR is that it is almost never effective, yet we persist in this ritual flogging of the dead. By definition we only attempt the procedure on dead people—folks with no pulse or respiratory effort—so the rate of success is understandably low. CPR works best with people who are young and healthy to begin with and suffer some sudden offense to the heart like electrocution or drug overdose. The first time I worked somebody up was early on a Christmas morning, a 27-year-old man who had been shot point-blank in the head. I pumped on him vigorously all the way to the hospital, rode the gurney like they do on television so I could keep doing compressions right into the E.R. Out of breath, I gave my report to a bored-looking trauma surgeon who glanced at me, glanced at the clock on the wall, and said only, "Time of death: 7:23. Thank you, gentlemen." End of story.

This call was different, though. Neither the family nor my crew had any hope that we could save this patient, and in fact none of us had any real desire to try. But protocol is protocol, so we dragged him out of bed and into the kitchen where we would have space to work. The captain and the driver from my crew began CPR while the other firefighter and myself (both paramedics) went to work. I got down on the floor at the patient's head, pried his mouth open with my laryngoscope and stuffed an endotracheal tube down his windpipe. The tube is more effective than a bag-and-mask system because it delivers pure oxygen directly to the lungs with no leakage. While I was securing the tube my partner had managed to insert a large-bore IV into the left arm. I called for epinephrine, 1 milligram, the front-line drug in most codes. I followed the epi with atropine, and we circulated both through the bloodstream with chest compressions. Every minute or so I stopped all the action and rechecked the heart monitor to make sure that the patient was still in flatline. We repeated the drug sequence one more time. The patient stayed dead, so we flipped off the monitor, stood up, stretched, and started clearing our mess. Only a coroner can touch a dead body after resuscitation efforts have failed, so we had to leave the poor guy naked and stuck full of tubes, lying on the linoleum. All because he never signed his "Do Not Resuscitate" form.

Walking out through the living room I noticed that most of the family was watching a Magnum P.I. rerun.

Zac Unger is a firefighter in Oakland, California.

Views offered in this article are those of the author and do not necessarily reflect the position of the Provincial Health Ethics Network.