Thinking about serious illness and life-saving measures that might be taken in a crisis is never pleasant. Unfortunately, with the advent of the coronavirus pandemic, many of us have been confronted with images of how painful life-saving measures can be. This is especially true when there is little hope that the measures will restore the patient to any real quality of life. A Do-Not-Resuscitate order, or DNR, is a legally binding medical order directing medical staff not to try to restart a patient’s heart or restore breathing if they suffer cardiac or respiratory arrest. What this usually means is that cardiopulmonary resuscitation (CPR) will not be performed. If no DNR is in place, medical staff would be obligated to perform CPR.
CPR is both much more painful and often less effective than it looks on TV (which is the only place most of us have seen it). CPR is most effective when used on otherwise healthy individuals. The effectiveness of CPR on frail elderly patients or those with significant medical issues is often much lower.
What’s more, CPR carries risk for frail patients, including broken bones, damage to organs, and the inability to breathe without a ventilator. It is easy to understand why some older patients choose to request and execute a DNR, allowing them to “slip away” rather than spend their last days in pain from “life-saving” intervention.
That is all well and good when an older person is able to make their own decision. What happens when a frail older patient is legally incapaciatated and has a guardian? Can the guardian execute a DNR for the protected person (ward)?
The short answer is that yes, a guardian can sign a DNR on behalf of a ward. However, given the literal life-and-death nature of this decision, Michigan law puts certain safeguards in place.
The guardian must have visited with the ward no more than 14 days prior to executing the DNR. If it is possible for the guardian to have meaningful communication with the ward, the guardian must consult with the ward about the order. The guardian must also consult with the ward’s attending physician regarding the specific medical indications warranting the DNR.
A sample form for the DNR is provided in Michigan statute, and in order to be valid, it must be in a written form that is “substantially similar” to the sample. The order must be signed by a “declarant;” ordinarily this is the person to whom the DNR refers, but in the case of a ward, the declarant would be the guardian.
The DNR form must also be signed by the attending physician, and two witnesses over the age of 18. At least one of those witnesses must be someone other than the patient’s spouse, parent, child, grandchild, sibling, or presumptive heir. In signing the DNR, the witnesses are attesting to the fact that the guardian appears to be of sound mind, and not under duress or undue influence.
The guardian must provide a copy of the signed DNR to the ward’s attending physician. If the ward lives in a facility, a copy must also be provided to the administrator of the facility. If the ward lives in a private home, a copy of the order should be available in the home. The point is that personnel who are most likely to need to know about the DNR should be made aware of it. To this end, a guardian may also attach a DNR bracelet to the ward’s wrist. This is not required by law, but is a practical option.
The guardian also has the right to revoke the DNR, which must be done in writing. The guardian must also notify the ward’s attending physician that the order has been revoked. If the ward lives in a care facility, the administrator of that facility must also be notified.
If the DNR is to continue for longer than a year, it must be reaffirmed. This reaffirmation requires that the guardian once again meet with the ward, and, if possible, have a meaningful discussion with the ward about reaffirming the order. In addition, the guardian must also consult with the ward’s attending physician about the basis for reaffirming the DNR.
If you are serving as a guardian of an older person, and it is possible to discuss their wishes with them, it is important to bring up the subject of a DNR. It can be difficult to talk about, but you and your ward will have greater peace of mind if you are able to honor their wishes on this important subject.