PLANT CITY, Fla. — Do not resuscitate orders, or DNRs, are issued by the Florida Department of Health and signed by doctors on behalf of people who do not wish to be resuscitated if their heart stops or they stop breathing.
The ABC Action News I-Team learned these legal documents aren’t always honored, which can lead to prolonged suffering for people who wanted a quick and painless death.
“A DNR is a do not resuscitate order,” said Tiffany Tergesen, who helped her elderly cousin Celeste Salanitri obtain a DNR after her health declined.
“It’s something my physician signs when the physician determines that my medical condition is significantly serious that I have a likelihood of dying,” said USF Healthcare Vice President Jay Wolfson, who is an attorney and has a doctorate in health care administration.
DNRs are required by law to be printed on bright yellow paper so it's not overlooked by medical personnel.
According to Florida Administrative Health Law, “An emergency medical technician or paramedic shall withhold or withdraw cardiopulmonary resuscitation” when they are presented with or observe a DNR order on a patient.
“You stand back and you let it happen,” Wolfson said.
But what Florida Lawmakers intended to be spelled out in black and white, can sometimes turn grey in the heat of the moment.
No pulse, no breathing, and a DNR
“We have a resident that’s not conscious, no pulse,” said an employee of a Plant City assisted living facility on the evening of April 1.
She called 911 to report that 81-year-old Celeste Salanitri collapsed in the bathroom in her room.
“I get the call from the facility. They tell me that she was unresponsive, they’re taking her to the hospital,” said Tergesen, her cousin and healthcare surrogate.
Salanitri’s had end-stage Parkinson’s disease. Her doctor had signed the DNR order just one week earlier. The document states that cardiopulmonary resuscitation is to be withheld.
An EMS report says that the DNR was presented to paramedics upon arrival by the facility staff.
“But for some reason they did it anyway,” Tergesen said.
Plant City Fire Rescue paramedics responded and according to the report discovered Salanitri had a weak pulse and shallow respiration.
But during the ride to the hospital, the report indicates her heart and breathing stopped. Instead of allowing Salanitri to die as she wished, the paramedics began CPR.
“She didn’t want to be resuscitated because that is an awful violent thing to have to go through,” Tergesen said.
The report said paramedics contacted their medical director, who advised them to continue.
“Perception may have been that she was gonna be okay or there was a chance that she could be revitalized,” Wolfson said. But that didn't happen.
CPR involves pushing the chest down two inches, 120 times a minute, which Wolfson said can leave a patient in worse shape than they were before.
“You’re gonna crack some ribs. You’re gonna possibly puncture a lung,” Wolfson said.
That’s what Tergesen believes happened to Salanitri.
Relatives endure 12 days of hell
“She would lay on her side and she would just gurgle. It sounded like she was drowning,” Tergesen said.
Her cousin was intubated after her breathing and heartbeat were restored.
Tergesen, as her healthcare surrogate, made the difficult decision to remove the tube because Salanitri indicated she didn’t want to be kept alive by artificial means in her living will.
What happened next was a slow death.
Tiffany Teregesen and her mother Lillian Tergesen spent the next 12 days by Salanitri’s side at a Hospice facility.
Salanitri never regained consciousness.
“The way she felt as I held her hand. Watching her slowly turn yellow as her kidneys were shutting down. Her fingertips turned blue slowly as the circulation stopped,” Tiffany Teregesen said, describing what happened.
“While it might not have been their intention, they brought her back so that she could die slowly,” Tiffany Tergesen said.
We talked to Lillian Tergesen by Facetime.
She and her cousin were born just months apart and remained best friends until Salanitri’s death.
Lillian Teregesen said she was heartbroken by the paramedics’ actions.
“You’re taking away the last wish of this person in this world,” Lillian Teregesen said.
Lillian said it was a relief when her cousin finally passed away.
“My family had to sit beside a bed and watch someone slowly die because of that one decision to violate this DNR,” Tiffany Teregesen said.
It's unclear how Plant City Fire Rescue will address the ignored DNR order.
Plant City Fire Rescue Chief David Burnett said the investigation is still ongoing and there is nothing to share at this time.
Practitioners are rarely punished for ignoring DNRs
Wolfson says that while the law is clear, consequences for failing to honor a DNR aren’t.
Wolfson said previous litigation regarding practitioners ignoring DNRs involved medical bills and legal bills incurred after the patient was resuscitated.
In some cases, the physician overrode a DNR order because of personal beliefs.
“But they have rarely punished civilly or criminally the healthcare provider or institution for ignoring it,” Wolfson said.
Wolfson said the rationale behind DNR orders is clear.
“Florida believes that patients have the right to self-determination. You and I have the right to say don’t touch me, don’t inject me with something, don’t save my life. Leave me alone. If I am dying, let me go,” he said.
A lesson learned the hard way
Wolfson believes punishment is not the answer in this case.
“This case was an aberration. It’s unfortunate. And the lesson that the family wants to be learned from this is let’s find a way to make sure that paramedics, EMTs and others may be better educated,” Wolfson said.
“She never would have wanted this for us,” Tiffany Tergesen said. “One decision five minutes between this facility and the hospital changed all our lives forever.”
Understanding a DNR, Living Will, and Health Care Surrogate and How It Impacts End of Life Care:
A DNR is essentially a prescription by a physician.
The yellow sheet can be posted on the refrigerator, on the door, or in another conspicuous place in the patient’s home.
A DNR is not something the patient signs, but something a physician signs when he or she determines that the patient has a medical condition that is significantly serious that the patient has a likelihood of dying or the likelihood of recovering from a cardiac event or stroke is very small and would affect the quality of the patient’s life thereafter would not be very good.
“I have a right to make that decision as a person with the physician’s determination that I’m in that medical condition that would not likely be subject to improvement,” said USF Healthcare Vice President Jay Wolfson, who is an attorney and has a doctorate in health care administration.
“It’s not just my saying don’t touch me. I put that in my living will,” he said.
A living will is a legal document signed by the person signed by its maker in the presence of two witnesses.
At least one of the witnesses has to be someone other than a spouse or blood relative.
The document said, “life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I will be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.”
People can add any additional or specific instructions to the document.
Florida residents are also encouraged to appoint someone to serve as their health care surrogate. This is a person appointed to provide consent for medical treatment and surgical diagnostic procedures in the event that a person has been determined to be incapacitated.
This document must also be signed in the presence of two witnesses, one of whom must not be a spouse or blood relative.
The documents for creating living wills and health care surrogates are linked above and do not have to be completed by an attorney.
The Florida Bar does recommend consulting an attorney before making important legal planning decisions.
For more information about how to find an attorney who specializes in this area of practice, contact the Florida Bar Lawyer Referral Service at 1-800-342-8011.
If you have a story you’d like the I-Team to investigate, email us at adam@abcactionnews.com.
