Futile cardiopulmonary resuscitation and physician authority for unilateral do not resuscitate orders

There is an emerging consensus today that specific case profiles exist in which in-hospital cardiopulmonary resuscitation (CPR) would be futile care and in which a do not resuscitate (DNR) order is medically appropriate. The physician's affirmative decision to perform CPR usually is made without involvement of the patient or the patient's family. On the other hand, DNR orders seldom are issued without consent of the patient or the patient's family, even though the patient is not likely to survive CPR. The concept of patient autonomy, however, does not extend to the patient and/or family a legal, ethical, or social right to futile care, particularly CPR that is futile. As such, the treating physician is not required to obtain the patient's and/or family's informed consent prior to issuing a DNR order, but has the unilateral authority to enter such an order.     

Do-not-resuscitate orders. Where are they in the prehospital setting?

Without a well-functioning, prehospital, do-not-resuscitate (DNR) system in place, emergency medical service (EMS) providers must resuscitate all patients who access the system, regardless of the patients' wishes and regardless of what makes ethical or economic sense. In lieu of valid documentation, it is not appropriate to withhold resuscitative measures in this critical, time-dependent situation. In order to help EMS systems implement functional prehospital DNR protocols, this paper reviews the state-of-the-art of prehospital DNR including the issues to consider when designing such a system and a discussion of the features of some of the existing systems. This review includes: 1) the basis and requirements of a DNR system; 2) legal and physical forms for DNR orders; 3) eligibility for DNR status; 4) reversal of DNR orders; and 5) inappropriate use of EMS systems for DNR patients. Finally, a more general discussion of overall resource utilization in prehospital resuscitations is presented to emphasize that implementing prehospital DNR systems is only one piece of a larger issue.     

Developing Do Not Resuscitate policies

It is clear that nurse administrators must take a leadership role in developing a DNR policy. The establishment of written DNR policies are necessary, not only to meet Joint Commission Standards, but also to improve communication, reduce ethical dilemmas, legally clarify patient status, and maintain consistent quality of care. Although a DNR policy cannot address and anticipate all problems, the interdisciplinary process used to develop DNR policies can provide the health care team with a base on which to build the policies, guidelines, and support mechanisms needed to deal with future ethical issues.     

Do-not-resuscitate order: a view throughout the world

Resuscitation has the ability to reverse premature death. It can also prolong terminal illness, increase discomfort, and consume resources. The do-not-resuscitate (DNR) order and advance directives are still a debated issue in critical care. This review will focus on several aspects, regarding withholding and/or withdrawing therapies and advance directives in different continents. It is widely known that there is a great diversity of cultural and religious beliefs in society, and therefore, some critical ethical and legal issues have still to be solved. To achieve a consensus, we believe in the priority of continuing education and training programs for health care professionals. It is our opinion that a serious reflection on ethical values and principles would be useful to understand the definition of medical professionalism to make it possible to undertake the best way to avoid futile and aggressive care. There is evidence of the lack of DNR order policy worldwide. Therefore, it appears clear that there is a need for standardization. To improve the attitude about the DNR order, it is necessary to achieve several goals such as: increased communication, consensus on law, increased trust among patients and health care systems, and improved standards and quality of care to respect the patient's will and the family's role.     

Deactivating the implantable cardioverter-defibrillator: a biofixture analysis

Automatic implantable cardioverter-defibrillators (ICDs) are becoming increasingly common, as is refusal of resuscitative efforts at the end of life, both by patients and surrogate decision-makers. While it is clear that a terminally ill patient who lacks decisional capacity may, through a surrogate, refuse cardiopulmonary resuscitation (CPR), is it appropriate for physicians to infer from such a refusal that the patient's ICD should be deactivated? A proper answer to this question requires consideration of the nature of consent to a do-not-resuscitate (DNR) order, the context in which permission is given for the writing of the DNR order, and the ontologic status of implantable devices in general and ICDs in particular. We introduce the concept of "biofixtures" and suggest that a biofixture analysis is a novel way of approaching the difficult ethical issues that may confound the care of patients with implantable devices.     

Ethics review: Perioperative do-not-resuscitate orders – doing 'nothing' when 'something' can be done

Cardiopulmonary resuscitation (CPR) has the ability to reverse premature death. It can also prolong terminal illness, increase discomfort and consume enormous resources. Despite the desire to respect patient autonomy, there are many reasons why withholding CPR may be complicated in the perioperative setting. This review outlines these factors in order to offer practical suggestions and to provoke discussion among perioperative care providers. Although originally described for witnessed intraoperative arrests, closed chest cardiac massage quickly became universal practice, and a legal imperative in many hospitals. Concerns were raised by both health care workers and patient groups; this eventually led to the creation of the do-not-resuscitate (DNR) order. However, legal precedents and ethical interpretations dictated that patients were expected to receive full resuscitation unless there was explicit documentation to the contrary. In short, CPR became the only medical intervention that required an order to prevent it from being performed. Before the 1990s, patients routinely had pre-existing DNR orders suspended during the perioperative period. Several articles criticized this widespread practice, and the policy of 'required reconsideration' was proposed. Despite this, many practical issues have hindered widespread observance of DNR orders for surgical patients, including concerns related to the DNR order itself and difficulties related to the nature of the operating room environment. This review outlines the origins of the DNR order, and how it currently affects the patient presenting for surgery with a pre-existing DNR order. There are many obstacles yet to overcome, but several practical strategies exist to aid health care workers and patients alike.     

Ethics review: Perioperative do-not-resuscitate orders – doing 'nothing' when 'something' can be done

Cardiopulmonary resuscitation (CPR) has the ability to reverse premature death. It can also prolong terminal illness, increase discomfort and consume enormous resources. Despite the desire to respect patient autonomy, there are many reasons why withholding CPR may be complicated in the perioperative setting. This review outlines these factors in order to offer practical suggestions and to provoke discussion among perioperative care providers. Although originally described for witnessed intraoperative arrests, closed chest cardiac massage quickly became universal practice, and a legal imperative in many hospitals. Concerns were raised by both health care workers and patient groups; this eventually led to the creation of the do-not-resuscitate (DNR) order. However, legal precedents and ethical interpretations dictated that patients were expected to receive full resuscitation unless there was explicit documentation to the contrary. In short, CPR became the only medical intervention that required an order to prevent it from being performed. Before the 1990s, patients routinely had pre-existing DNR orders suspended during the perioperative period. Several articles criticized this widespread practice, and the policy of 'required reconsideration' was proposed. Despite this, many practical issues have hindered widespread observance of DNR orders for surgical patients, including concerns related to the DNR order itself and difficulties related to the nature of the operating room environment. This review outlines the origins of the DNR order, and how it currently affects the patient presenting for surgery with a pre-existing DNR order. There are many obstacles yet to overcome, but several practical strategies exist to aid health care workers and patients alike.     

Perioperative do-not-resuscitate orders--doing 'nothing' when 'something' can be done

Cardiopulmonary resuscitation (CPR) has the ability to reverse premature death. It can also prolong terminal illness, increase discomfort and consume enormous resources. Despite the desire to respect patient autonomy, there are many reasons why withholding CPR may be complicated in the perioperative setting. This review outlines these factors in order to offer practical suggestions and to provoke discussion among perioperative care providers. Although originally described for witnessed intraoperative arrests, closed chest cardiac massage quickly became universal practice, and a legal imperative in many hospitals. Concerns were raised by both health care workers and patient groups; this eventually led to the creation of the do-not-resuscitate (DNR) order. However, legal precedents and ethical interpretations dictated that patients were expected to receive full resuscitation unless there was explicit documentation to the contrary. In short, CPR became the only medical intervention that required an order to prevent it from being performed. Before the 1990s, patients routinely had pre-existing DNR orders suspended during the perioperative period. Several articles criticized this widespread practice, and the policy of 'required reconsideration' was proposed. Despite this, many practical issues have hindered widespread observance of DNR orders for surgical patients, including concerns related to the DNR order itself and difficulties related to the nature of the operating room environment. This review outlines the origins of the DNR order, and how it currently affects the patient presenting for surgery with a pre-existing DNR order. There are many obstacles yet to overcome, but several practical strategies exist to aid health care workers and patients alike.     

Suicidal Patients with a Do-Not-Resuscitate Order

Background

A suicidal person with a do-not-resuscitate (DNR) order presents an ethical dilemma to the emergency physician. Many believe that suicide is an irrational action, and therefore, all suicide attempts must be treated. Others believe a DNR order should be respected even in the setting of a suicide attempt.

Changes in how ICU nurses perceive the DNR decision and their nursing activity after implementing it

This study investigated the perceptions and attitudes of ICU nurses towards the 'do not resuscitate' (DNR) decision and changes in their nursing activities after implementation of the DNR decision in South Korea. A data survey was conducted in South Korea between August and October 2008, with a convenience sample of 252 ICU nurses who had more than one year of clinical experience. The data were collected via a self-administered questionnaire. Most of the nurses perceived the necessity of the DNR decision in cases where there would be no chance of patient recovery despite massive efforts. Very few of the nurses' activities changed, either passively or actively, after implementation of the DNR decision. Moreover, the findings of this research provide suggestions for the future direction of the DNR decision and ethical nursing guidelines in South Korea. Further investigations are needed for the development of decision-making skills and intervention guidelines for end-of-life nursing.     

Hospice and the Do-Not-Resuscitate Order

Recent passage of the Patient Self-Determination Act will require health care providers to develop policies concerning patients’ wishes for life prolonging therapy. Since American hospice programs have generally had do-not-resuscitate (DNR) policies since their inception we thought it timely to review the experience of hospice programs with the DNR order. Many programs assume that a signed DNR order is a prerequisite to being accepted as a hospice patient. Other programs are more flexible. This lack of uniformity exposes the unresolved issue within the hospice community as to what is considered appropriate hospice or palliative care. Problems with paramedics responding to 911 calls and not respecting DNR orders or living wills are also discussed.     

Do-not-resuscitate order after 25 years

BACKGROUND: In 1976, the first hospital policies on orders not to resuscitate were published in the medical literature. Since that time, the concept has continued to evolve and evoke much debate. Indeed, few initials in medicine today evoke as much symbolism or controversy as the Do-Not-Resuscitate (DNR) order. OBJECTIVE: To review the development, implementation, and present standing of the DNR order. DESIGN: Review article. MAIN RESULTS: The DNR order concept brought an open decision-making framework to the resuscitation decision and did much to put appropriate restraint on the universal application of cardiopulmonary resuscitation for the dying patient. Yet, even today, many of the early concerns remain. CONCLUSIONS: After 25 yrs of DNR orders, it remains reasonable to presume consent and attempt resuscitation for people who suffer an unexpected cardiopulmonary arrest or for whom resuscitation may have physiologic effect and for whom no information is available at the time as to their wishes (or those of their surrogate). However, it is not reasonable to continue to rely on such a presumption without promptly and actively seeking to clarify the patient's (or surrogate's) wishes. The DNR order, then, remains an inducement to seek the informed patient's directive.     

The do-not-resuscitate decision: the context, process, and consequences of DNR orders

This study examines the process and consequences of an increasingly important element of the dying experience in American hospitals: the writing of a Do-Not Resuscitate (DNR) order. The focus of the study is on the decision-making process and timing of the DNR decision, the impact of the DNR order on the dying experience, and the consequences of the DNR order for length of hospital stay and accrued medical charges. Patients with a DNR order are compared to those who were unsuccessfully coded. Data are obtained from a review and analysis of the medical charts and death monitor sheets of a sample of 249 persons who died in 1994 in a single teaching hospital. The study found that physicians routinely discuss the DNR decision with patients and/or their surrogates (though patients are involved in the decision in only about one-third of cases) and that the decision is often made relatively early in the hospital stay. The dying experience of patients with a written DNR was different in significant ways from the experience of unsuccessfully-coded patients. Those with a DNR were more likely to remain in a single unit in the hospital and less likely to die in an intensive care unit or while connected to a ventilator. Consistent with other studies, however, average length of hospital stay and average medical charges were actually higher for the DNR patients. Implications of these differences between DNR and unsuccessfully-coded patients are discussed.     

THE DO-NOT-RESUSCITATE DECISION: THE CONTEXT,PROCESS, AND CONSEQUENCES OF DNR ORDERS

This study examines the process and consequences of an increasingly important element of the dying experience in American hospitals: the writing of a Do-Not Resuscitate (DNR) order. The focus of the study is on the decision-making process and timing of the DNR decision, the impact of the DNR order on the dying experience, and the consequences of the DNR order for length of hospital stay and accrued medical charges. Patients with a DNR order are compared to those who were unsuccessfully coded. Data are obtained from a review and analysis of the medical charts and death monitor sheets of a sample of 249 persons who died in 1994 in a single teaching hospital. The study found that physicians routinely discuss the DNR decision with patients and/or their surrogates (though patients are involved in the decision in only about one-third of cases) and that the decision is often made relatively early in the hospital stay. The dying experience of patients with a written DNR was different in significant ways from the experience of unsuccessfully-coded patients. Those with a DNR were more likely to remain in a single unit in the hospital and less likely to die in an intensive care unit or while connected to a ventilator. Consistent with other studies, however, average length of hospital stay and average medical charges were actually higher for the DNR patients. Implications of these differences between DNR and unsuccessfully-coded patients are discussed.     

When CPR is not an option

What is to be learned from this situation? First, although Mr. Lockwood's consent for the DNR order is not needed, there is an obligation to communicate openly and clearly with the family and ensure that Mrs. Lockwood's advance directive is respected. This might mean a DNR order needs to be written. Also, there is an obligation to discuss goals of care with the family. The second lesson is that you should reflect on your employer's CPR policies and practice, and ask the following questions: Do the policy and/or practices support saying "no" in a situation such as Mrs. Lockwood's? Also, how does the policy support staff when there is a request for futile CPR, either from a competent patient or from a patient's family? What are the expectations about communication with the family when there is an advance directive and/or when CPR is found to be futile? Knowing what you ought to do for patients is not sufficient. Often you cannot act on these decisions because of the environment. If the policies are not in accord with the CNA Statement on Resuscitative Interventions, you should collaborate with colleagues to revise the CPR policy and practices. By doing so, you will be meeting your obligation to help foster and support a practice environment that promotes ethical, competent and compassionate nursing care.     

Trends from the United States with end of life decisions in the intensive care unit

Objective To describe the changes that have occurred in the United States since medicine has moved away from a paternalistic model to one that promotes patient autonomy and self-determination. To discuss the implications for cardiopulmonary resuscitation (CPR) and the increasing use of when not to perform CPR and other life-sustaining therapies. To describe the various interpretations of the ritual term Do-Not-Resuscitate (DNR) and to introduce the concept of futility in the context of non-beneficial over-treatment and discriminatory under-treatment.Setting Selected clinical, philosophical and public policy literature and two illustrative case examples.Results 1. There is no longer a mandate to perform CPR on all dying patients, even though the Council on Ethical and Judicial Affairs of the American Medical Association in 1991 said that the only restrictions should be in patients with an irreversible terminal condition or when the physician writes the order, DNR. 2. The DNR order ususally requires the informed refusal of CPR by the patient or family. There is only minimal support for a unilateral decision even for patients with far advanced disease. 3. DNR is often the first step in the negotiated process of forgoing care in the ICU. There are multiple interpretations of DNR both in and outside of the ICU. 4. Health Proxy is the latest attempt to have a person clarify his/her wishes and preferences by naming a decision maker, if the individual losses mental capacity. 5. Although ethical principles seem well established, there are inconsistent interpretations and practices at the bedside in the United States in part due to the restructuring of the relationship between physicians and patients, providers and consumers/clients. 6. Objective severity scores such as Apache III, SAPS II, MPM II are generally not applicable for individual patient end-of-life decisions.Conclusions Although Health Proxy in its current formulation has been disappointing, there is a clear trend for wider application of DNR and for more active discussions about withholding or forgoing other life-sustaining therapies. DNR has a different interpretation late into the ICU course (>72h) than when applied at or shortly after ICU admission. Late in the ICU course, it has been decided by the medical team and family or surrogate decision maker/Health Proxy that the patient has failed or is in the process of failing aggressive ICU therapy. Early use of DNR may be related to limitations based on pre-existing chronic or subacute disease burden or an unwillingness to proceed with a full ICU course of therapy. It is unclear how Ethics Committees, risk management and hospital administrators, national practice guidelines, governmental sponsored health care reform will interface with the highly complex individual patient — physician — family — Health Proxy interface as practiced in the United States. Dialogue between the Society of Critical Care Medicine and the European Society of Critical Care Medicine and among interested physicians could provide a format for a multi-cultural context to discuss end of life issues in the ICU setting.Based in part on lecture presented at French Medical Ethical Society (La Décision D'Arrêt Therapeutique en Réanimation), June 21, 1991, Pont à Mousson, FranceSupported in part by the Richard and Edith Strauss Canada Foundation     

Insights into Chinese perspectives on do-not-resuscitate (DNR) orders from an examination of DNR order form completeness for cancer patients

Purpose

Discussing end-of-life care with patients is often considered taboo, and signing a do-not-resuscitate (DNR) order is difficult for most patients, especially in Chinese culture. This study investigated distributions and details related to the signing of DNR orders, as well as the completeness of various DNR order forms.

Methods

Retrospective chart reviews were performed. We screened all charts from a teaching hospital in Taiwan for patients who died of cancer during the period from January 2010 to December 2011. A total of 829 patient records were included in the analysis. The details of the DNR order forms were recorded.

Results

The DNR order signing rate was 99.8 %. The percentage of DNR orders signed by patients themselves (DNR-P) was 22.6 %, while the percentage of orders signed by surrogates (DNR-S) was 77.2 %. The percentage of signed DNR forms that were completely filled out was 78.4 %. The percentage of DNR-S forms that were completed was 81.7 %, while the percentage of DNR-P forms that were completely filled out was only 67.6 %.

Conclusion

Almost all the cancer patients had a signed DNR order, but for the majority of them, the order was signed by a surrogate. Negative attitudes of discussing death from medical professionals and/or the family members of patients may account for the higher number of signed DNR-S orders than DNR-P orders. Moreover, early obtainment of signed DNR orders should be sought, as getting the orders earlier could promote the quality of end-of-life care, especially in non-oncology wards.     

Preliminary Development of Two Predictive Models for DNR Patients in Intensive Care

The purpose of this study was to identify which variables are the best predictors of a do-not-resuscitate (DNR) classification and develop a model to predict the nursing care required by DNR patients in the ICU. Data collected on DNR and non-DNR patients included nursing care requirements, severity of illness, resource allocation and sociodemographic characteristics. One model identified the best predictors of a DNR classification in intensive care as the origin of admission and the severity of illness score on the day of admission to intensive care. The second model identified the best predictors of nursing care requirements for DNR patients in intensive care as the number of days spent in intensive care prior to the DNR order, the average daily resource allocation points after the DNR order, and the severity of illness score on the day the DNR order was designated.     

Cardiopulmonary resuscitation: are practitioners being realistic?

Cardiopulmonary resuscitation (CPR) is now established medical practice for all in-hospital cardiac arrests except where a specific 'do not resuscitate' (DNR) order is in place. This article explores many of the ethical and moral issues surrounding CPR and the use of DNR orders. It examines the success rate of in-hospital CPR and raises the question of what constitutes outcome success by illustrating that at best only 15% of resuscitated patients survive to hospital discharge. The article proposes that both patients and healthcare professionals grossly overestimate the success of CPR and suggests that many elderly patients might choose not to be resuscitated if they were allowed to make an informed choice. It concludes by suggesting that further work needs to be undertaken with regard to early assessment of all in-hospital patients, combined with realistic and frank communication between healthcare professionals and patients if futile, undignified and costly deaths are to be avoided.