What If the Family Disagrees With the DNR Order?

Three weeks after his heart transplant, Andrey Jurtschenko still hadn’t woken up. A towering figure at 6 feet, 3 inches, with salt-and-pepper hair and a matching mustache, Jurtschenko, known as Andy, was known for his sense of humor and endless supply of wisecracks. He underwent surgery for a new heart on April 5, 2018, hoping for renewed energy and a return to his carpet business and weekend outings to watch New York Mets games. However, as the days passed and Andy didn’t revive like most patients do after transplant surgery, his children, Chris and Megan Jurtschenko, grew increasingly worried.

On April 26, a neurologist broke the devastating news to Chris that an MRI had revealed Andy’s brain likely lacked oxygen during the procedure, leaving him in a vegetative state. In conversations prior to the surgery, Andy had expressed his desire not to burden his family or live in an incapacitated state. Now, as Andy couldn’t voice his wishes, Chris and Megan had to speak on his behalf. On April 27, they met with the medical team to request a do not resuscitate (DNR) order should Andy’s heart stop beating.

Dr. Margarita Camacho, the surgeon who performed the transplant, resisted their request, claiming it was too early for a DNR order and that there was still hope for recovery. Despite feeling conflicted, Chris and Megan acquiesced at Camacho’s urging. However, they continued to press the issue and finally obtained a DNR order over a month later.

The reluctance of Newark Beth Israel Medical Center’s transplant team to sign DNR orders was not unique. Former employees and staff meeting recordings revealed a hesitancy to sign DNRs, especially before key performance metric dates. The team lacked a proactive approach to discuss code status with patients before their conditions became critical.

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Although the transplant program’s policies were deemed consistent with best practices, concerns arose due to its focus on taking on sicker patients for transplantation. Newark Beth Israel’s heart transplant program aimed to help patients who might be rejected by other programs, often operating on older and more complex cases. The pressure to maintain good one-year survival rates influenced the team’s reluctance to approve DNR requests, potentially impacting a patient’s end-of-life care.

Conflicts regarding DNR orders stem from the complex nature of decisions involving resuscitation on the brink of death. Hospitals have faced legal consequences for resuscitating patients with existing DNR orders or disregarding a family’s request for resuscitation in cases deemed futile. Subjectivity often surrounds these decisions, with doctors expected to respect patients’ autonomy and wishes, including those expressed through health care proxies.

The situation is further complicated in heart transplant cases. During the operation, a DNR order cannot be in place since the patient’s new heart often requires interventions like chest compressions and electric shocks to ensure proper functioning. However, once the surgery is complete, patients or their surrogates should be able to request DNR orders at any time.

Often, these discussions occur too late, when seriously ill patients are unable to participate. Meaningful conversations regarding code status should take place earlier, respecting the patient’s individual goals and preferences. Medical teams should not force treatment on patients or their surrogates, ensuring autonomy is upheld.

Megan Jurtschenko fondly remembers childhood visits to her father’s carpet store, where she would play among the stacks of samples. Her father, Andy Jurtschenko, worked his way up from humble beginnings to open his own store. However, in 2012, Andy’s health began to decline due to congestive heart failure, forcing him to stop working and rely on disability benefits. Knowing their father would not want to be kept alive by extraordinary means, Megan and Chris made every effort to ensure his caregivers understood his wishes.

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After Andy’s heart transplant, complications continued to arise. One incident at Newark Beth Israel left Megan shaken when she discovered her father’s code status hadn’t been updated as per their request, meaning resuscitation would be attempted if his heart or breathing ceased. Megan fought for a DNR order, refusing to leave the hospital until one was issued.

Despite the DNR order being in place, Dr. Mark Zucker, the director of the transplant program, questioned Megan’s decision. His comments about “giving up” added to the emotional strain the family was already enduring.

Andy Jurtschenko eventually returned to the rehab facility, but his condition only improved modestly. He never regained full independence and experienced physical and cognitive decline. After months of suffering, Andy passed away on October 31, 2018, with no attempts at resuscitation.

The story of Andy Jurtschenko and the challenges his family faced during his end-of-life care highlights the complexities and emotional struggles surrounding DNR orders. Hospitals and medical teams must engage in open and timely discussions with patients and their families to honor their wishes. By prioritizing patient autonomy and individual goals, medical professionals can provide compassionate and respectful care in these difficult situations.

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