Mr R had numerous health challenges. The 67-year old’s life had not been easy. A childhood bone infection resulted in his needing 3 hip replacements. He suffered from congestive heart failure, chronic atrial fibrillation, and chronic pain. A recent stroke had caused blindness in one eye, and over the past decade, Mr R had undergone a coronary artery bypass, aortic valve replacement, cervical spine fusion, and 2 lumbar fusions. His declining health and need for pain medication over the last several years had made it hard for him to enjoy the outdoor activities he had always loved.

After being admitted to the hospital for shortness of breath, weakness and lower extremity edema, Mr R’s physician suggested a cardioversion to try to stabilize his heart rhythms and relieve some of his symptoms. Mr R knew he was not going to get better, and he did not expect any procedure to change that, but he agreed to the procedure in the hopes that it would relieve some of his pain and discomfort.

Prior to the cardioversion, Mr R thought long and hard about his quality of life and future, and he decided that if he died during the procedure he would not want to be revived. He discussed it with his wife, and despite her initial reluctance, she understood and agreed with her husband’s wishes. Mr R filled out all the appropriate paperwork to signify his Do Not Resuscitate/Do Not Intubate (DNR/DNI) requests and told the hospital staff that he wished to have the DNR/DNI entered on his electronic chart.

Later that day, Mr R suffered a cardiac arrest and collapsed in the hospital bathroom. The nurse who found him unresponsive on the floor pulled the emergency cord located in the bathroom. Nothing happened. When the nurse realized the emergency cord had not worked, she tried the mobile dispatch system, which also was having problems. Finally, the nurse hit the code blue button in Mr R’s room and a code was called.


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A team of at least 10 burst into the room and began performing cardiopulmonary resuscitation (CPR) on Mr R. He was administered epinephrine. At some point, someone realized that there was confusion about Mr R’s DNR status. A nurse was sent to call his wife to clarify. Mrs R confirmed her husband’s DNR wishes, but by the time the nurse got back, 10 minutes had passed, and Mr R had a pulse and was breathing on his own again. He was taken to the intensive care unit, which is where he was when he came to and realized he had not been allowed to die.

The physician looked embarrassed as she explained how in the confusion of the emergency, hospital staff had inadvertently not heeded Mr R’s DNR order. The physician’s apology did little to pacify Mr R, who was bruised and battered from the CPR, and who would require care for the rest of his life.

Mr R eventually returned home but was never the same. He spent his final 2 years tethered to an oxygen tank, confused, weak, and unable to care for himself. His anger did not dissipate – he blamed the hospital for depriving him of what he considered a natural death, and extending his suffering.

He hired a plaintiff’s attorney and sued the hospital, alleging a variety of things including negligence and battery. Mr R died 2 years after the DNR incident, and his wife, as she had promised, saw out the rest of the case.