Death by Prescription. Pt 2.

       Not all that many years ago, when I was on sabbatical at Duke University in N. Carolina, I was privileged to meet a particularly gifted  neurologist who was a consultant to the University Stroke Unit, the department where I  was spending some of my sabbatical time.  We used to lunch together occasionally, and in the course of our conversation we discussed 'do not resuscitate' orders.  Understand, we were not talking about euthanasia.  My position was that if a patient had written an advance directive stating that in the advent of a catastrophic event and the patient had previously documented, while of sound mind, that he did not wish to be resuscitated, there was no debate, the wishes of the patient must be obeyed.
    " Not necessarily so," said  the Neurologist,  who was the sort of doctor I would like to be looking after me when I arrive at my neurological emergency.
     "It's obvious, " I said.
     "If the patient had that view when he was not suffering from  any acute medical  situation, he might just have a different mind-set when confronted with an acute life threatening emergency."
      "How would you determine that?" I asked.
      "I did try to devise a research project to answer that question once," he said.
      "Well, send me the results?" I asked.
      " I terminated the project without writing it up"  he answered. "Let me explain.  I reviewed a cohort of patients who had opted for no resuscitation in  the event of a disabling stroke and requested that I be called in the event of their sustaining such an event.  First, of course, I sought and obtained the collaboration of all my colleagues on the stroke unit.   My plan was that I  would try to establish contact with each of these patients, despite the fact that many of them were unable to  speak.  I devised methods of communication so that even many of the patients who could  not speak or communicate easily would be able to answer yes or no to their previously expressed view.  I am sure there were many shortcomings in my pilot project, but I did not receive a single confirmation that despite the neurological catastrophe none of the patients wished to adhere to their previous decision to die.   They had changed their minds!   You understand why I decided to cut short the project on the basis that the results would be more likely to add to the confusion than shed light on it.". 
        As far as I am aware, no-one has attempted to validate the previous decision of  DNR in terminal stroke or other life-threatening  conditions.  If the Neurologist's impression of an almost universal last minute change of mind  about the 'Do Not Resuscitate' order held, no DNR order would ever be valid again.   It might even be that we are not resuscitating patients who have changed their mind but are unable to communicate their reviewed wishes!
       Death by no prescription is a tricky business too!