Dear Family Advisor

My mother has asked not to be resuscitated if she has a medical crisis, but my siblings disagree on what constitutes a medical crisis.

Last updated: May 19, 2008

Before she showed signs of dementia, my mother decided she didn't want extreme measures to be taken to save her life, and she authorized a Do Not Resuscitate order. Now my siblings can't agree about when we should honor it. Some don't want to call 911 if my mother becomes unconscious or shows signs of stroke or heart attack, because DNRs are notoriously difficult to enforce. Others are adamant that she be taken to the hospital for the staff there to determine if her problem is life threatening, and then we should deal with the DNR order.

Talking with my mother about this would only cause more trouble. Her dementia has advanced, her logic is not always great, and she changes her mind a lot. If she changes her mind about the DNR, at least a couple of my siblings will question her mental capacity, which could stir up a legal (and emotional) mess. Can you offer advice?

I applaud you for wanting to clarify this issue now. It sounds as if there are more than a few siblings in your family, and it's probably difficult for you all to agree on many things -- especially on something as difficult as this. But if not everyone in the family knows about or supports your mother's DNR, you may end up arguing about it when it's time to make a decision. Under those circumstances, many doctors and hospitals will opt for aggressive care -- the opposite of what your mother wanted -- as the "safest" alternative.

Your siblings' opinions probably vary based on their history, fears, moral beliefs, and relationships with your mom. An in-person meeting among all of you, if that's possible, would provide a good opportunity for everyone to get out all their thoughts and feelings. Hopefully, no matter what your personal differences are, you can all agree that your mother's wishes should be honored.

Most people don't want their loved ones to die and they're hoping that things can get better -- but dementia and many other illnesses don't get better. If your mother has chosen not to live this way if a medical crisis arises, that should be respected. It may take someone who isn't a family member -- such as a social worker, chaplain, or hospice mediator -- to help you to come to a decision everyone can honor.

First, I suggest that your family pick a health surrogate (also called a health care agent), the person who has the power to make medical decisions for your mother if she can't make them on her own. If you're involved with a home health agency, a social worker can meet with you to help you determine the best person for this role. Usually it's the family member who's most involved, lives nearby, and is willing to make these decisions under stress and uncertainty. You can designate a line of succession in case the first person chosen is unavailable when a medical crisis arises. All family members must respect the decision of the health surrogate.

Second, does your mother just have dementia, or are there other health-related issues involved? Is her condition far enough along that it's time for hospice to get involved? If it is that time, hospice can help mediate a family discussion and help you come to agreement on a health surrogate.

In general, DNR orders apply to situations in which a person's heart or breathing has stopped. Each state has its own parameters for DNRs and other Advance Health Care Directives, based on state law. You can get a better idea of the laws where your mother lives by searching the terms statutes outline and advance health care directive for your state on the Internet. Or request a list of the statutes from a local hospice organization in her area. You'll also find out what her state honors -- some states require people living at home to wear DNR bracelets that indicate their wishes, for example. In any event, it's wise to make sure that your mother's doctor, health surrogate, other family members, and anyone else who may be involved have a copy of her DNR.

Since you took the initiative to ask this question, it seems that you're willing to be involved and want this settled so that you can do right by your mom. You might use your peacemaker role to bring everyone together and hash out some agreements.

After the issues are resolved, I hope that your family members can focus more on your mother at this time than on how her death is to be handled. Whether she dies in weeks, months, or years is a moot point compared to the time you spend with her now.

Taking responsibility for another person's life is a sobering experience. I had to take that role with my mother, and it was scary. It's a role that's best suited for loving, involved family members. If that person is you, don't allow guilt, regret, or fear to overtake you. Make the best decision you can, and spend the time you have with your mom in peace.