Do not resuscitate please. DNR orders, or do not resuscitate orders, aren’t very tricky when it comes to the law and how the law is carried out, and interpreted by doctors and patients embarking on a palliative care end-of-life plan. A DNR order means do not use medical interventions to restore breathing and respiration if these bodily systems are already failing or have failed. People who request DNR orders are typically very sick, dying already; or the curative medical intervention is too invasive, painful, or risky to endure and continue living at a certain quality of life.
DNR orders, palliative care, and end of life treatment are complex, emotionally raw, and ‘bipolar‘. Discussing with people looking into or exploring these medical pathways can often lead to mountain top discussions, low, sad. Sorrowful moments are very tricky for skilled service workers not to feel the countertransference issues included in working with this population of people.
Most conversations around end of life treatment and even DNR orders are also most often relegated to strictly medical situations. We usually don’t use these terms used in mental health treatment or when mental health care is provided during therapy. It is so strange to me, as I often think about the quality of life I want for myself.
In terms of healing, most of us in recovery either have a ways to go before we say, I’m good with where I am at in terms of my mental status and the recovery journey. Like me, some people lose too much ground by the very nature of our chronic mental health condition that we need to practice recovery and healing methods all the time to stay on top of our health.
In terms of quality of life, I use this concept to map out my goals, measure my progress towards better health, and better understand where I am in the more fantastic clinical picture of treatment. I am at the bare minimum of what I consider acceptable to continue living and feeling okay about my general health and its implications for my lifestyle and medical status. To more precise, if things got any worse. In terms of my mental quality, symptoms, energy input required to offset disordered thinking and its impact on my feelings and well-being. I would throw in the towel and say,
‘Ya, basta!’ Enough is enough.
I am not saying I want to die. I am certainly not suicidal. I am, however, very realistic and self-aware of my health. I know the impact of further medical or psychiatric issues would overwhelm my coping skills and too much for me to want to ever deal with every day for the natural duration of my life. So, when I say I want to submit a DNR order to my doctor, perhaps my meaning and reasoning are beginning to become more apparent. Indeed, further issues related to respiration and medical interventions that may cause more harm than good in an already complicated comorbid medical and psychiatric case like myself are absurd to consider. I never want CPR or help to re-establish respiration.
At the root of it, when it comes to your own decisions, quality of life is at the very heart of it. What do you want for yourself and your future if you couldn’t decide on a medical intervention that would restore your life at the cost and risk of losing or damaging other vital organic, cognitive, and vocational abilities?
I know, for myself, if I lose any more ‘functional’ areas, or further ground around my ability to complete ADL’s, or would need additional medication, it is too much even to consider living. The sheer complexity of all these factors interacting would make my life so difficult to manage independently and would probably require hiring medical staff or living in a medical/nursing unit.
At 34, living such a life beneath the threshold, I deem ‘OK’ to dehumanise my spirit when it comes to life quality. Living out a life incongruent with my chosen quality of life erodes a piece of my character, my essence, and who I am, and what I want for my life. To take this away, to bring me back into a life where I am in even more pain, is beyond contemplation for me. In these cases, I want out!
As I said, I find it extraordinary conversations around DNR are localized to hospitalizations and mainly around health care proxies. So, who will make medical and psychiatric decisions if your condition gets worse? You aren’t able to communicate your health and medical desires to the doctors. If we are to honour the pain of psychic impairments and mental health distress or extreme states, then having a frank talk about DNR’s for people with complex comorbid psychiatric issues makes perfect sense. These need to be ingrained into treating people with severe psychiatric problems and medical complexities, which further aggravate quality of life and cast doubt around the need to carry out any further interventions.
Sometimes, contemplating death and accepting our bodies’ limits puts our health into a better perspective. At other times, it can put our wants and needs in life at the forefront of the conversation. Making it very clear what our quality of life needs to be for living. In the end, the only final thing is how we choose to live our lives instead of life, and its circumstances, making that decision for us in some tragic turn of events. The only thing genuinely sad is not knowing which you want before it’s too late.
Max E. Guttman, LCSW is a psychotherapist and owner of Recovery Now, a mental health private practice in New York City.