The Hospital Ignored My Mother’s Do Not Resuscitate Order

“Her heart stopped, she was ready to go. That’s how she viewed it.”


My mom had a great view on life.

She very much wanted to live her life until her very last breath.

About five years before her death, my mom was diagnosed with congestive heart failure. And although she was not preparing to die, she was okay with when it might happen.

Her heart stopped, she was ready to go. That’s how she viewed it.

In fact, the most important thing to her was that when her heart did stop, there would be no attempt to revive it.

And so, every time she went into the hospital, she wanted nurses to put her Do Not Resuscitate (DNR) order in her record. She would even ask for it to be placed on the door of her room.

If she could, she probably would have asked to have it tattooed onto her arm.


If you live with someone who has congestive heart failure, you know that each moment of crisis is like a step down the ladder that you don’t really recover from. With each crisis, your health worsens. You’re steady for a while until you have your final crisis.

We went through a series of these crises with my mom.

Each time she would go into the hospital, we had no idea whether she would come out. After a while, we assumed she would because, after all, she made it through the last one.

But when she went into the hospital in November of 2009, her step down was a big one. And we didn’t know it.


That night, November 15th, 2009, I called my brother to ask whether I needed to be there. My brother, who is a physician, told me “no, I think she’s going to be alright. I think it’s just another one of these episodes.”

But it wasn’t alright.

Later that evening, my two older sisters had arrived to see her, and after spending some time sitting with her, they asked if she would mind if they went downstairs for something to eat.

Minutes after they left the room, her heart stopped. She was gone. She had lived life how she wanted to, on her terms, until her very last breath.


But staff quickly rushed to her bedside and attempted to do a full code to restart her heart.

The hospital staff failed to see the DNR order in her file and attempted to restart her heart, the one thing she did not wish for.

Thankfully, my mom was a willful person. She did not come back.

And my family and I felt so blessed that she didn’t. But we were so angry at the hospital.


We asked the workers, what were you thinking? Why did you ignore her explicit DNR order? What happened?

We quickly learned the hospital staff were good people. The hospital was and is a good hospital. The problem was the hospital culture.

The culture said that if someone died on your shift, that was a bad thing Extension of life was a good day. Someone dying on your shift was not.

And so when my mother’s heart stopped, they went into autopilot, not even thinking to ask themselves about her end of life wishes. This happens in hospitals everywhere, and it happens every single day.


Culture is a powerful thing. In order to honor the end of life wishes of those we serve, we must look at incidents like that of my mother as stemming from a cultural challenge.

I think if every one of us who works in the medical field resolves to never tolerate these types of incidents, not even one, we can become the examples our organizations need to drive change and shift this extension-of-life-at-all-costs culture.

Because we must make end of life what it should be, what we want it to be, what we know the people we serve want it to be: a human, healing, sacred experience for individuals and their loved ones.


Mark B. Ganz is President and CEO of Cambia Health Solutions, where he guides its path to delivering a seamless, end-to-end, health care experience. He is a past chairman of the board for America’s Health Insurance Plans, and currently serves on the board of directors for the Blue Cross and Blue Shield Association. He shared this story during his 2017 End Well talk.

This article is part original, part transcript of the 2017 End Well Symposium talk given by Mark B. Ganz. You can view Mark’s full End Well talk here.

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