Futility and the ethics of resuscitation

Article Abstract:

Recently, in cases that the physician judges to be futile, the ability to limit the use of cardiopulmonary resuscitation (CPR) and other lifesaving techniques has been actively discussed. In the past, any such judgement by a physician was dismissed on the grounds that it deprived the patient of autonomy and was ethically unacceptable. The present article discusses the duty and obligation of the physician to act in the best interests of the patient. In some cases, the physician either withholds or never discusses with a patient therapies or treatments that he or she believes to be inappropriate or futile. For example, a physician may not discuss the use of antibiotics with a patient who has a viral cold, because antibiotics are ineffective in destroying that virus. The judgement to withhold antibiotics in this case, however, is not absolute; in some cases, antibiotics could help to alleviate bacterial infections that accompany the virus. Other cases in which a treatment could be deleterious, or even lethal, make the case clearer. Physicians are morally able to refuse cardiac surgery to patients who are unlikely to improve, or who have a low probability of surviving such surgery. Why is CPR different? If the futility of CPR and the possibility of a poor or unacceptable outcome is high, why can't CPR be withheld? A discussion of the value of CPR with either the patient or his/her caregiver should be more focused on the patients's quality of life and whether CPR would be futile, rather than on the process of consenting to withhold CPR. (Consumer Summary produced by Reliance Medical Information, Inc.)

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Family consent to orders not to resuscitate; reconsidering hospital policy

Article Abstract:

It is standard procedure in most hospitals that a patient be given cardiopulmonary resuscitation (CPR) unless there is a written order not to resuscitate (DNR orders) in the patient's chart. Typically, before a DNR order can be written by a patient's physician, the patient or a family member acting as a surrogate for the patient must consent to it. The authors of this report claim that in some cases the present policy subjects patients to futile procedures and a prolongation of pain. Two cases describe terminally-ill children, who were not allowed to die peacefully because of the decisions of their surrogates. The authors argue that hospital policy should allow physicians to write DNR orders against the explicit wishes of surrogates when the pain and burden of therapy outweigh the potential gains to the patient; the surrogate can not give a suitable reason to establish the need to continue life; and the physician has made his or her best efforts to mediate with the surrogate. When, in the best judgment of the attending physician, CPR has no clear benefit to the patient, the physician should be relieved of the responsibility of gaining family consent before posting a DNR order. (Consumer Summary produced by Reliance Medical Information, Inc.)

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Ethical considerations in resuscitation

Article Abstract:

All patients have the right to refuse medical treatment, including CPR, and they should make their wishes known in an advance directive. Doctors should not be required to administer CPR if they believe the effort will be futile. However, CPR should be attempted in any individual who suffers a cardiac arrest outside a hospital, and it should be continued until it is clear that the individual can not be revived. Many patients want to discuss their desire for resuscitation should they need it, and doctors should discuss this option with all patients admitted to the hospital, not just those who are most ill. CPR should be given to all hospitalized patients who arrest, unless there is a do-not-resuscitate (DNR) order. The Patient Self-determination Act of 1991 requires hospitals to provide all Medicare and Medicaid patients with written information about advance directives.

Care and treatment, Cardiac arrest

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