Mr. Jay's Case
Mr. Jay, a 71-year-old man with severe chronic obstructive pulmonary disease, was convalescing at a skilled-nursing facility after a hospital stay for pneumonia. Mr. Jay and his doctor discussed the likelihood that his bouts with pneumonia would reoccur and the possibility that his lungs might stop working during a future episode of pneumonia.
The doctor explained that for Mr. Jay attempting resuscitation following a pulmonary arrest was not likely to succeed. The doctor further explained that even if resuscitation restarted his lungs, Mr. Jay would require aggressive care in an intensive care unit.
Given these prospects, Mr. Jay told his doctor he would prefer that resuscitation not even be attempted. The doctor wrote an order not to attempt to resuscitate Mr. Jay. Thereafter, Mr. Jay developed increasing shortness of breath and decreasing responsiveness over 24 hours. The nursing facility staff called for an ambulance. The paramedics found Mr. Jay unresponsive, with a respiratory rate of 8 breaths/min and oxygen saturation at 85% on room air.
Although Mr. Jay had ask his doctor to order that resuscitation not be attempted, the paramedics did not have a protocol that would permit them not to attempt resuscitation – so they did.
Mr. Jay was still unresponsive when the paramedics arrived at the hospital’s emergency department. He was afebrile, with a systolic blood pressure of 190 mm Hg, a pulse of 105 beats/min, a respiratory rate of 8 breaths/min, and an oxygen saturation of 88% despite supplemental oxygen. He had diminished breath sounds without wheezes, and a chest X-ray showed large lung volumes without consolidation.
Arterial blood gases showed marked respiratory acidosis. Although Mr. Jay had been covered by his doctor’s order not to attempt resuscitation the ER doctor’s order was, “Full code for now, status unclear.” After intubating and sedating Mr. Jay in the ER he was transferred to the intensive care unit where he died one week.