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.     

How--and when--to obtain consent for do-not-resuscitate orders. Clinical guidelines and strategies for resolving conflicts

Consider a do-not-resuscitate (DNR) order when a patient's presumed consent for cardiopulmonary resuscitation (CPR) is in question, the patient has an illness that is terminal or severe and irreversible, or he or she is permanently unconscious or likely to have cardiac or respiratory arrest. The patient with decisional capacity has the right to give or withhold consent for a DNR order. State law may limit a surrogate's authority to request that CPR be withheld. Remember, a DNR order does not restrict a patient's access to intensive care. Nurses, patient advocates, social workers, and clergy members may help mediate disputes. If necessary, seek advice from an ethics committee on how to resolve the conflict.     

Should there be a choice for cardiopulmonary resuscitation when death is expected? Revisiting an old idea whose time is yet to come

Since closed chest cardiac massage was introduced in 1960, the notion that cardiopulmonary resuscitation (CPR) attempts are not appropriate for all patients has been consistent. Over the years, leading authorities have clearly articulated that for patients who are dying irreversibly and expectedly medical decisions for do-not-resuscitate (DNR) orders should be made by physicians, because in such cases CPR attempts are not indicated. Physicians are not obligated to and should not offer or provide useless treatments, even in the name of patient autonomy. Despite this, physicians still seek and obtain patient or proxy consent when CPR is not indicated before writing a DNR order. Reasons include fear of legal repercussions/misconceptions, limited physician-patient relationships, time constraints, and institutional culture. End-of-life plans of care should be based on appropriate goals that focus on palliation and not on aggressive medical treatments that offer no benefit.     

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.     

Clinical perspectives on portable do-not-resuscitate orders

A do-not-resuscitate (DNR) order is a written medical order that documents a patient's wishes regarding resuscitation and, more specifically, the patient's desire to avoid cardiopulmonary resuscitation (CPR). A DNR order is one of the most important patient care directives that can be issued because it has dramatic and irreversible consequences. A portable DNR order is a do-not-resuscitate directive that travels with the patient. One way to improve continuity among providers and organizations is to develop statewide portable DNR and end-of-life orders that ensure patients' wishes are followed regardless of setting.     

Limiting care: is CPR for everyone?

Current research on the efficacy of CPR in specific patient groups may lead to the withholding of CPR in groups that statistically show minimal success. Prognosticative factors that indicate minimal-at-best success with CPR include age greater than 70, dysrhythmias such as asystole and electromechanical dissociation, sepsis, metastatic cancer, GI hemorrhage, and acute stroke. Although physicians are under no legal or ethical obligation to provide futile treatments, how one defines a treatment as "futile" is unclear. As a patient advocate, the nurse acts to ensure the autonomous patient is fully informed, freely consenting, and actively directing his/her own health care. End-of-life decisions regarding health care must be based on the patient's goals, which will be revealed through the moral discourse among health care professionals, patients, and their loved ones.     

L'ordre « ne pas réanimer » en soins intensifs. Aspects éthiques et position du Conseil d'éthique clinique des hôpitaux universitaires de Genève (Suisse)

The order NTBR (“Not To Be Resuscitated”), or DNR (“Do Not Resuscitate”), or DNAR (“Do Not Attempt a Resuscitation”) is totally specific. It is a medical order prescribing not to begin a cardiopulmonary resuscitation (CPR) when a cardiac and/or respiratory arrest has occurred. This order must not be confounded with the orders to limit or to terminate vital treatments (“withholding” and “withdrawing”), particularly in the intensive care setting. The Clinical Ethics Committee of the University Hospital of Geneva (Switzerland) has recently published guidelines on the DNR order. Essentially, in this text, the authors put the emphasis on the exceptional importance of such an order, which must be written and periodically actualized. This order is ethically acceptable when a competent patient refuses to be submitted to a CPR, or when a patient is severely ill and close to his death. In this latter situation, it is not necessary to discuss this order with the patient, but his expectations and wishes must be discussed however. An information for young physicians concerning DNR orders must be organized by the hospitals.     

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 influence of do-not-resuscitate orders on care provided for patients in the surgical intensive care unit of a cancer center

Results of this study indicate that critically ill cancer patients who had a DNR order written while in the SICU received less medical intervention after the order was executed, whereas supportive nursing care remained unchanged. Addressing DNR issues in cancer patients earlier during their hospital course or even as outpatients may better serve patient and family wishes and reduce unnecessary costs of futile care.     

Attitudes towards do-not-resuscitate decisions: differences among health professionals in a Portuguese hospital

OBJECTIVES: Implementation of an in-hospital cardiopulmonary resuscitation (CPR) program stresses the need to discuss do-not-resuscitate (DNR) orders, as CPR may not be desirable in some terminally ill patients. Ethical, social, educational, and professional issues may influence these decisions. This study was designed to evaluate attitudes among four categories of healthcare professionals. DESIGN AND SETTING: Survey in a tertiary hospital in Portugal. METHODS: An anonymous self-completed questionnaire was distributed to 825 staff members, 527 of whom responded (20% physicians, 44% nurses, 20% health technicians, 16% healthcare domestic staff). Responses were compared between the various health professional groups. RESULTS: The level of medical/health training was positively related to the frequency of DNR decisions (physicians and nurses could foresee more circumstances warranting DNR decisions than technical/administrator or domestic staff) and negatively related to the willingness to include the patient's family in the DNR decision (physicians and nurses saw less need for the family's participation than technical/administrator or domestic staff). Significant differences were also found between professional groups regarding the physician's responsibility and the nurses' participation in DNR decisions. There was no difference between the professional groups regarding the need to note the DNR decision in clinical charts. CONCLUSION: Health professionals differ in their attitudes concerning DNR decisions. In particular, the level of medical/health training and/or degree of involvement with the patient's daily care may play an important role in DNR decisions.     

Do Not Resuscitate orders and older patients: findings from an ethnographic study of hospital wards for older people

BACKGROUND AND AIM: This paper reports on the findings from an ethnographic study involving three wards in two hospitals in the Northwest of England and focuses on the controversial issue of Do Not Resuscitate (DNR) orders. The study aimed to explore the way in which terminal care was provided to older patients and examined the way in which DNR orders were a socially constructed part of the practices of both nurses and doctors. METHOD: An ethnographic approach was adopted that used participant observation and semi-structured interviews with nurses and doctors. A purposive sample of 28 qualified nurses and five medical staff were interviewed. The decision-making process of DNR orders became the focus of the interview questions. FINDINGS: The findings reveal that DNR decision-making was largely socially constructed from the interactions of hospital staff. Patients were not asked their preference and were excluded from any decision-making about Cardiopulmonary Resuscitation (CPR) or DNR orders. Two major findings emerge. First, DNR orders and the non-use of CPR could be seen as a form of medical beneficence, resulting from the often described paternalistic attitudes of hospital doctors. Second, there was a clear indication that DNR orders and the non-use of CPR for certain patients was based on improving the quality of patients' lives. CONCLUSION: The study raises issues about the quality of care received by frail older patients whom the nurses felt would not survive a futile medical procedure. The conclusion considers the need for hospitals to formulate and implement CPR policies, particularly in the prevailing climate in which patients are encouraged to become active participants in their own health care.     

Establishing incidence and administrative protocols for do not resuscitate orders

An order not to resuscitate refers only to CPR and does not imply the omission of any other type of medical care. Institutional DNR policies should include specific statements reflecting resuscitation for those without DNR orders, the patients' wishes, medical conditions, roles of family, protocol describing the process for DNR orders, scope of DNR orders, and frequency of review of DNR orders. The most common reasons for not having written DNR protocols were that directors of nursing did not have guidelines for or did not feel qualified to develop policies, and that they were not sure of the legal implications of such policies. An interagency ethics committee can serve as an advisory committee, but all medical and nursing decisions should be made by the appropriate professional, based on agency policy.     

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     

Futility and unilateral decision making: a different view

...Resuscitation of PVS patients is futile if the goal is to restore the patient to a cognitive or conscious state but not if the goal is restoration of respiratory function. The judgment of futility in either case is based on nonmedical (as well as medical) values or criteria, i.e., the value of cognitive life vs. the value of noncognitive life. If all of the affected parties concur that noncognitive recovery is a goal not worth achieving, a DNR order should be written. Lacking such concurrence, justification for a DNR order might be found in societal assessment of the burdens and benefits to others (besides the patient) of providing treatment in such circumstances. This is not a decision to be made unilaterally by a single physician, whose values are not necessarily reflective of those of the patient, family members, other physicians, or society at large.     

Clinical practice guidelines for resuscitation in acute care hospitals

The development of the AHA Guidelines for CPR and ECC and the AARC RACH Clinical Practice Guideline should both be instrumental in improving the performance of RCPs on in-hospital resuscitation teams. The AARC and AHA are assuming important leadership roles in this movement by publishing CPGs for CPR and ECC. RCPs with ACLS training are in a prime position to assume more responsibility on resuscitation teams within acute care facilities. They should be prominent members of the resuscitation team--committed to the entire team's performance--and be actively involved in ACLS training. The first step in that process is to study the current levels of RCP competence in ACLS. Further, RCPs and health-care providers should define the goals of resuscitation in terms of long-term survival, quality of life, and years of useful life after CPR. The cost of inadequate attention to which patients should have DNR orders is a drain on the entire health-care system. Research on the impact of disease categories on CPR outcome should be used to educate physicians, nurses, and RCPs so they can help patients better understand their chances of regaining their pre-CPR quality of life. Successful CPR outcome should be carefully defined using the patient's disease category. Each patient should be individually evaluated for DNR orders. As suggested by Schwenzer, "Patients' perception of their quality of life before and after CPR should guide their and our decisions." However, we must all accept the responsibility for defining the limitations of medical technology and try to determine when CPR is futile.     

What is a good death? Issues to examine in critical care

The decision to limit care for critically ill intensive care patients is not uncommon, and most deaths in the intensive care unit are now preceded by do not resuscitate (DNR) orders, which are regarded by some as a way to make death more humane and respect patient autonomy. When a patient receives a poor diagnosis the family needs to discuss the medical care and respect the patient's wishes. Many relatives hesitate to discuss these issues, because they wish to avoid discussing the idea of death or any serious change to the patient's condition. This article aims to address DNR orders and discuss the mechanisms available to achieve a good death for patients and their relatives, instead of enduring a distressing and undignified end.     

Legitimating do-not-resuscitate orders: a discursive study of cancer patients' speech

This article examines how patients with cancer construct and legitimate do-not-resuscitate (DNR) orders. Semi-structured interviews with 23 outpatients attending an oncology clinic were tape-recorded, transcribed, and analyzed in accordance with discourse-analytic methodology. Results indicate some variability for participants regarding the meaning of DNR orders, which were nonetheless viewed as appropriate and desirable. The patient's subsequent death was legitimated primarily through the invocation of highly valorized discourses within Western society: nature, autonomy, and compassion. Non-compliance with DNR orders, or the instigation of CPR was seen as violating nature, infringing autonomy, and as uncompassionate. The combined effect was to construct dying as a natural event which is the concern of the individual patient and their family, endorsing medical non-intervention in the process. This research provides support, from the patients' viewpoint, for a policy of non-intervention when death is imminent and inevitable, and for those questioning the wisdom of a default policy of initiating CPR on any hospitalized patient, especially those patients inevitably in the process of dying.     

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.     

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.