When I had 30 nursing home patients, one of them, Mr. Otto A., fainted several times and proved to have a cardiac dysrhythmia (Atrial flutter) for which the best treatment then was placement of an implanted pacemaker. I went to tell him, but his Alzheimer’s disease, then moderate, made it difficult. He played tunes from the 1920s on the piano, but could not follow my explanations. I patiently explained, several times over, during a long interview. Finally he said, “Oh, so if I don’t have one of these machines put in my chest I might just crump!” “Exactly!” “Nope. I don’t want one. If I crump like that it would be the best way to go!”
This man understood me clearly, despite his poor memory, and was sufficiently informed about the procedure. Furthermore, he had made it very clear that he did not wish us to ever attempt resuscitation in the event of sudden death. I noted a DNAR order in his medical record and our conversation and did not refer him to a cardiologist for a pacemaker.
Some time later, he fell and broke his hip. Standard care is to have surgery to put in hardware to hold the fracture together. It is better than the alternative: prolonged bedrest and immobilization in traction, with a high risk of blood clots, pneumonia, and bedsores. So, he was taken to hospital. I recorded his DNAR order also. Then I was told “You can’t do that!” for a guy going into surgery. But as his family doctor, I knew that his wishes were clear, and they overrode hospital “standard procedure.” I insisted, and was told all the liability would be mine. He had his surgery, did well, returned to the nursing home, and survived longer without a pacemaker. I’ve forgotten now how he eventually died.
Family medicine is an intimate field of relationship with and advocacy for patients. This story became a North Star for me: the difficult task of obtaining informed consent or refusal with a demented person, my role as his advocate, bucking standard procedures, and having an outcome I could not just live with but be proud of. It wasn’t easy, but Otto taught me to be a better doctor.