The DNR Litmus Test: High Heels and Lipstick

THE ONE QUESTION YOUR FAMILY SHOULD BE ABLE TO ANSWER ABOUT YOUR ADVANCE DIRECTIVE

“I would want to live as long as I could still ___.” This is one of the most critical questions to define your end-of-life wishes. It is so critical that I have termed it your “Do Not Resuscitate (DNR) Litmus Test.” (Before reading more about the Litmus Test, you should first learn about DNR orders.)

One of the hardest parts about discussing advance directives with family members is the vast unknown of the context in which your wishes will be applied. You might say to your family “in the event of a terminal illness, I do not want heroic measures.” But, is that terminal illness going to be a catastrophic stroke, end-stage cancer, advanced dementia, or an aggressive infection? Each of these scenarios calls for wildly different possible medical treatments — an invasive brain procedure, a permanent ventilator, a feeding tube, or a significant surgery.

It is especially challenging to have these conversations about your medical wishes when you have limited exposure to the medical decisions that might arise. After all, what are these “heroic measures” if you’ve never seen them up close? The answer is you do not need to know medical treatments, but rather understand your personal goals. In other words, these conversations are about values and one way to name those concretely is to create your DNR Litmus Test.

The Litmus Test is where you think about which basic activities still represent a quality of life for you. Your Medical Power of Attorney (POA) can then subject your likely medical outcomes to that test. In other words, you ask yourself, “my life would be worth living as long as I could still ___” and you fill in what that level of function would be for you.

As long as I could still…

• Walk the dog
• Read the newspaper
• Meet my friends for a round of golf
• Manage my garden
• Talk to my family
• Take myself to the bathroom
• Live on my own (not in a nursing home)
• Recognize my family

Imagine the scenario where the doctors offer, say, a feeding tube for your advanced dementia because you’ve stopped eating in the last weeks of life. However, your goal is to always be able read the newspaper and you’re no longer able to do that due to your dementia. A feeding tube would not fix your ability to read the newspaper. Therefore, your POA can justifiably decide to forgo such an intervention as it would be inconsistent with your goals. In other words, the feeding tube fails your Litmus Test.

Alternatively, if you have a stroke and the doctors think an invasive surgery will likely reverse the brain injury and allow you to read your newspaper, your POA may opt for that. Having a good Litmus Test allows your POA to feel comfortable and confident in their medical decisions for you.

Here is an another example. One intensive care physician I used to work with was dressed to the nines everyday. Even when most doctors wore scrubs daily, she wore high heels and lipstick. (She could run across the hospital faster on those heels than I could run in tennis shoes.) She used to joke, “If I stop wearing my heels and lipstick, make me DNR, because that means I am no longer myself.” We laughed, but if she, say, had a stroke where she would no longer be able to take care of herself, we sure as heck knew not to perform CPR on her to bring her back to a state where she would not want to live.

So spend time thinking about your Litmus Test. What activities are key to your quality of life? What are the minimum activities that make you who you are and what you value? Are they physical activities, cognitive activities, or both?

As always, discuss your Litmus Test with your POA as they will be the one applying this knowledge to your medical care.