Community Coalition for End of Life Care



Imagine a boxer fighting to win. The bell rings and he heads for his corner. His trainer patches his eye, squirts him with water and gives him a pep talk. The bell rings, the boxer jumps up and he begins the fight again.

As a nurse practitioner, I'm in my frail elderly patients' corners, patching them up, giving them advice and cheering them on to fight the good fight against all their sufferings. I have an idea of the odds they face. I hope they have a chance of winning. At least I hope they don't get hurt too bad. But eventually, there comes a time when it is not a good fight any more. Yet, not to acknowledge this and to continue fighting would only cause them more suffering. It's not about winning anymore. It's about wisdom. It's not about prolonging the fight. It's about avoiding the suffering. My advice no longer considers saving them for another round. Rather my advice comforts them and relieves their pain, relieves their worries. We all leave the ring of life eventually, we all die.

With this in mind, think about the day your heart will stop. Perhaps you have lived your life and knew this day would come. Perhaps, you feel it is not so bad to die on this day.

But wait! Someone is pushing on your chest! Your bones are cracking! You suddenly feel as if you stuck your finger in a very powerful bare light socket! Electricity zaps your chest! Your heart starts to painfully pound and you awake but can't talk, can't think, and then you fade back into a perpetual state of disturbing dreams and nightmares.

What just happened? Well, someone saw you stop breathing, and also determined you no longer had a pulse. Someone started CPR. Someone shocked you with a defibrillator. You could say that someone just tried to patch you up and throw you back in the ring, just one more time, just to see how you would do.

Unfortunately, you really had lived the majority of your life. Unfortunately, you really wanted a peaceful death, and unfortunately, you never PUT IT IN WRITING that you wanted to die a natural death! You never carried that piece of paper that said "DO NOT RESUSCITATE", "NO CPR"! So you missed your chance for a peaceful death. After all those years of fighting to make a living, enduring your own particular suffering, the joys and the sorrows, someone had to throw you back in the ring, like a dead fish, just to see if by some miracle, you had any fight left in you.

Some would say "Oh well, no harm done! He was dead, anyway." But there was harm done. Certainly your cracked ribs from the pounding you took during chest compressions harmed you. Certainly, the lost opportunity for a peaceful death harmed you, particularly since you never wanted to be a burden to your family. Now they have a $10,000 medical bill to pay for your fruitless attempted resuscitation. How about the endless nightmares you endured under the influence of potent drugs and machines in the ICU for a few days?

Even if you had survived, you would likely be damaged neurologically. For a frail elderly person suffering cardiac arrest, especially outside of a hospital, and especially if you have any underlying chronic disease, the odds of surviving attempted cardiopulmonary resuscitation with any reasonable level of remaining neurological function are extremely remote. Unless you want to donate your body to science, or to the practice of procedures by emergency personnel, there really isn't any good reason to want CPR outside of the hospital if you are that elderly person.

If you don't have a "DO NOT RESUSCITATE" order signed by your doctor or nurse practitioner, then on that inevitable day when your heart stops, the decision will be out of your hands. Many people who have acknowledged that the majority of their life is past, and many who know they will not win the fight against their mortality, are still subjected to attempted cardiopulmonary resuscitation (CPR), even sometimes when it is obvious that they are dead or have little chance of neurological survival. There are reasons why this happens. Unless you carry a bonafide document stating that you do not want attempted CPR, then CPR is encouraged! Emergency personnel respond to calls in 'action' mode; it is hard for them to 'stand down' and not start resuscitative efforts without clear direction from you (and their Medical Director).

If you think what I am saying in this short article might apply to you or your frail elderly kin, do yourself, and others, a favor, and complete a "DO NOT RESUSCITATE" order with your doctor or nurse practitioner. They can give you the individual true odds of surviving another round in the ring of life given your condition and life expectancy. Sometimes wisdom isn't a bad thing. If you've already gone the full number of rounds, heard the bell many times, won a few, lost a few more, then it might be time to put into writing what you want to happen at that final bell.

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