A few years ago, when I was a hospitalist (meaning my practice was hospital-based and consisted only of acutely ill, hospitalized patients), I used to hang out a lot in the emergency room, especially in the middle of the night. I genuinely liked the excitement of a city emergency room, and I learned a great deal from my emergency medicine colleagues. There were several patients we knew well there; we called them the "ER regulars" because they came to our emergency room so routinely. One man in particular was rushed to our emergency room at least once a week.

Johnny was what we called a "lunger." He was 61 years old and suffered from chronic obstructive pulmonary disease, caused by years of heavy smoking. The emergency medical technicians (EMTs) would wheel him into the emergency room as he lay gasping for breath. Johnny used all the muscles of his upper body to try to move air through his pursed lips. His wife, Grace, was always close behind.

The thing about Johnny was that he wanted to die. He told us his life had become unbearable, and we believed him. Just struggling to breathe every day took all of his energy. But because he was often delirious from a lack of oxygen, we didn't think he was mentally competent to consent to a "do not resuscitate" (DNR) order. When I had a psychiatrist evaluate him, Johnny just yelled, "Go to hell with your psycho-babble," and refused to cooperate. Grace could not bear the thought of losing her husband and would not sign a DNR consent form, so every time he arrived at the hospital in respiratory distress, we resuscitated him.

Johnny explained his situation to me like this: Go run ten laps around the hospital grounds and then try to catch your breath by breathing through a drinking straw. "That's my life," he stated dryly. When I suggested he stop smoking, he asked sensibly, "Why? Would I live longer? Would I get better?" When I said I didn't know, he laughed and accused me of lying. "Just let me die, Doc. That's all I ask. I'm nothing but a burden to that poor woman," he lamented, referring to Grace.

At 3 a.m. one night, the EMTs called in to say they were on their way with Johnny. The emergency room doctor, two respiratory therapists, several nurses, and I were waiting for him when they wheeled him in. Johnny was nearly dead. As we prepared to resuscitate him, one of the nurses pulled a small piece of paper from between Johnny's hands.

The nurse read the note and yelled, "DNR! He's DNR!" The note, written on a prescription pad and signed by his primary-care physician, said, "Do Not Resuscitate!" We froze and looked at each other. Just then, his wife charged through the emergency room doors, screaming, "This is the worst he's ever been! He can't breathe! Please help him!" The emergency room doctor barked at me, "Kevin, you know this guy better than us. Is he DNR? Is this a legal document?" One of the nurses suggested calling the hospital attorney. They all looked to me for an answer. "There's no time. Let's just intubate," I uttered instinctively, not wanting to just watch Johnny die. Grace just kept saying, "I didn't give permission, and it's my decision to make!" Making matters worse was the fact that Johnny's primary-care doctor was one of the most respected doctors in the community, and he was on vacation.

I personally felt it was appropriate to abide by Johnny's wish to be allowed to die. And his primary-care doctor apparently agreed. But the hospital psychiatrist had previously declared Johnny "mentally incompetent to understand the ramifications of a DNR order." And his wife wanted him to live. "Just intubate!" I repeated, and the emergency room doctor slipped the tube into Johnny's windpipe as the respiratory therapists got the respirator ready, and then we wheeled him up to the intensive-care unit.

Johnny did not get better. I ordered an EEG to test his brain function, and he was declared brain-dead. He had sustained permanent brain damage due to a lack of oxygen to the brain. When Johnny's primary-care doctor arrived back from vacation a few days later, he came to see him. "Congratulations, Kevin," he snapped sarcastically. "I hope you're proud of what you've done here."

Grace eventually agreed to let us shut off the respirator. But before we did this, we had to follow hospital procedure and involve the ethics committee as well as the hospital lawyer. Everything took longer than necessary. Finally, the plug was pulled, and Johnny died. I stood and looked at his body after everyone left. He lay there with a big plastic tube coming out of his mouth; there was adhesive tape all the way around his head, holding the tube in place. I was glad Johnny wouldn't have to feel his hair being pulled out by the tape when it was finally removed. I studied the tattoos on his arms; one said, "Johnny + Grace -- 1953." They had been married for 43 years.

In the end, I guess it all came down to love. Johnny loved Grace so much that he didn't want to be a burden, and Grace loved Johnny so much that she couldn't picture life without him. And I couldn't help feeling I had let them both down by acting out of fear of legal liability and an instinct to heal even a dying man. I still wonder if I should have pushed harder for the DNR order. Should I have involved their three grown children early on? Now, I think the answer is yes; I should have taken my role as doctor one step further -- by helping Grace let Johnny die with dignity.