Unanswered questions about DNR orders

Article Abstract:

There is no disagreement over the fact that when people die, they suffer cardiac arrest. When patients who are otherwise healthy suffer cardiac arrest, they can often be restored to health by cardiopulmonary resuscitation (CPR), but for those who have other serious diseases, CPR simply prolongs death. The American Medical Association (AMA) proposes guidelines for do-not-resuscitate (DNR) orders in the April 10, 1991 issue of The Journal of the American Medical Association, but there will not be total agreement among physicians. That CPR should not be provided when it is futile is an obvious statement, but physicians may well disagree on the definition of futility. While some situations are clear, many others are not, and the physician should not make decisions unilaterally. A judgment of the futility of a few extra days of life in the hospital is subjective, and a patient may elect CPR even though there is only a two percent chance of survival. The same physician would not offer surgery to a patient with such a dismal outlook. Nor is patient autonomy an absolute, because it may conflict with such principles as not doing harm. In decisions about CPR, the use of futility as a guideline muddles the conflicts between values and goals. The question should really be whether CPR is a worthy goal in a patient who is dying, given the needs of others and the resources available. Scarce medical resources are better directed toward patients who may live. Physicians often advise medical personnel to perform ''show'' codes so that the family will feel that all means were used to keep the person alive. This is improper, and the physician should instead discuss matters with the patient or a surrogate. Because some patients do not want to talk about CPR and DNR orders when they are seriously ill, physicians are advised to make the discussion of CPR routine for all patients admitted to the hospital for medical or surgical care. Suggestions for a discussion about CPR and DNR are provided. (Consumer Summary produced by Reliance Medical Information, Inc.)

Laws, regulations and rules, editorial

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Guidelines for the appropriate use of do-not-resuscitate orders

Article Abstract:

Cardiopulmonary resuscitation (CPR) was originally administered to otherwise healthy people who suffered cardiac or respiratory arrest during surgery or after almost drowning. Now it is used on anyone who experiences cardiac or respiratory arrest, even when these events occur as a person is dying. Hospitals have specialized teams to administer CPR, and the consent of the patient is presumed. Consequently, CPR is frequently performed on individuals who are terminally ill or who may survive only briefly. CPR may be deemed successful if heart function is restored, or it may be defined more stringently, based on whether or not the patient lives to be discharged from the hospital. Generally, one-third of patients survive CPR, and one-third of the survivors live to be discharged, with survival being dictated by the underlying cause of the arrest. Patients with metastatic cancer who receive CPR do not usually survive to be discharged, and low survival rates accompany neurological diseases, kidney failure, respiratory failure, infection, and multiple organ failure. CPR procedures result in invasive treatment, transfer to intensive care units and, in many cases, repeat CPR. Although CPR is commonly administered, the patient can decide to forego it, or the doctor can judge that it would be futile, and a do-not-resuscitate (DNR) order can be written. Only a minority of patients ever make their wishes known to their doctors, but a recent study of 244 inpatient deaths noted that 68 percent of the charts had DNR orders. In another study, it was found that most patients wanted to discuss life-prolonging treatment with their doctors, but had never had the opportunity to do so. The American Medical Association Council on Ethical and Judicial Affairs has updated its resuscitation guidelines to take into account the issues of futility, patient incompetence, and ethical obligations. The Council advises physicians to discuss CPR with their patients. (Consumer Summary produced by Reliance Medical Information, Inc.)

Cardiac resuscitation

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Answers and questions about ethics consultations

Article Abstract:

Intensive care units should ask for an ethics consultation more often. According to a study published in 2003, a consultation with the hospital's ethics committee can limit the use of life support systems that will not benefit the patient. However, intensive care units should also provide more palliative care rather than simply limiting futile treatments.

Public affairs, Ethics, Editorial, Critical care medicine, Ethics committees

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