a physician, on the medicine wards you come across patients with "DNR"
or "Do-Not-Resuscitate" orders on their chart. You also find yourself
in situations where you are asked to discuss with a patient his or desires
concerning resuscitation following a cardiac arrest or life-threatening arrhythmia.
many other medical decisions, deciding whether or not to resuscitate a patient
who suffers a cardiopulmonary arrest involves a careful consideration of the
potential clinical benefit of intervention, the patient's preferences
for the intervention, and the likely outcome. Decisions to
forego cardiac resuscitation are often difficult because of real or perceived
differences in these two considerations.
should CPR be administered?
Cardiopulmonary resuscitation (CPR) is a set of specific medical procedures
designed to establish circulation and breathing in a patient who's suffered
an arrest of both. CPR is a supportive therapy, designed to maintain perfusion
to vital organs while attempts are made to restore spontaneous breathing and
If your patient stops breathing or their heart stops beating in the hospital,
the standard of care is to perform CPR in the absence of a valid physician's
order to withhold it. Similarly, paramedics responding to an arrest in the
field are required to administer CPR in most legal jurisdictions. In some
locations in the United States patients may have a valid "at home DNR
order" that allows a responding paramedic to honor a physician's order
to withhold CPR. However, often a posted "at home DNR order" or
a bracelet worn by a patient is not enough to prevent such intervention. What
is more useful is for the patient to make certain that caregivers at home
are well aware of his or her desires concerning such interventions to prevent
the calling of emergency personnel.
can CPR be withheld?
Virtually all hospitals have policies which describe circumstances under which
CPR can be withheld. Two general situations arise which justify withholding
CPR is judged to be of no medical benefit (also known as "medical futility";
see below), and
the patient with intact decision making capacity (or when lacking such
capacity, someone designated to make decisions for them) clearly indicates
that he / she does not want CPR, should the need arise.
is CPR "futile"?
CPR is "futile" when it offers
the patient no clinical benefit. When CPR offers no benefit, you as a physician
are ethically justified in withholding resuscitation. Clearly it is important
to define what it means to "be of benefit." The distinction between merely
providing measurable effects (e.g. normalizing the serum potassium) and providing
benefits is helpful in this deliberation.
is CPR not of benefit?
One approach to defining benefit examines the probability of an intervention
leading to a desirable outcome. CPR has been prospectively evaluated in a
wide variety of clinical situations. Knowledge of the probability of success
with CPR could be used to determine its futility. For instance, CPR has been
shown to be have a 0% probability of success in the following clinical circumstances:
other clinical situations, survival from CPR is extremely limited:
should the patient's quality of life be considered?
CPR might also seem to lack benefit when the patient's quality of life is
so poor that no meaningful survival is expected even if CPR were successful
at restoring circulatory stability. Judging "quality of life" tempts prejudicial
statements about patients with chronic illness or disability. There is substantial
evidence that patients with such chronic conditions often rate their quality
of life much higher than would healthy people. Nevertheless, there is probably
consensus that patients in a permanent unconscious state possess a quality
of life that few would accept. Therefore, CPR is usually considered "futile"
for patients in a persistent vegetative state.
CPR is deemed "futile," should a DNR order be written?
If CPR is judged to be medically futile, this means that you as the physician
are under no obligation to provide it. Nevertheless, the patient and/or their
family should still have a role in the decision about a Do-Not-Resuscitate
(DNR) order. This involvement stems from respect for all people to take part
in important life decisions, commonly referred to as respect for autonomy
or respect for person.
many cases, the patient/family, upon being given a caring but frank understanding
of the clinical situation, will agree with the DNR order. In such cases a
DNR order can be written. Each hospital has specific procedures for writing
a valid DNR order. In all cases, the order must be written or cosigned
by the Attending Physician.
if CPR is not futile, but the patient wants a DNR order?
As mentioned above, a decision to withhold CPR may also arise from a patient's
expressed wish that CPR not be performed on her. If the patient understands
her condition and possesses intact decision making capacity, her request should
be honored. This position stems from respect for autonomy, and is supported
by law in many states that recognize a competent patient's right to refuse
if the family disagrees with the DNR order?
Ethicists and physicians are divided over how to proceed if the family disagrees.
At many medical centers, the policy is to write a DNR order only with
If there is disagreement, every reasonable effort should be made to communicate
with the patient or family. In many cases, this will lead to resolution of
the conflict. In difficult cases, an ethics consultation can prove helpful.
Nevertheless, CPR should generally be provided to such patients, even if judged
about "slow codes"?
It is the policy at most medical cemters that so-called "slow-codes," in which
a half-hearted effort at resuscitation is made, are not ethically justified.
These undermine the right patients have to be involved in inpatient clinical
decisions, and violates the trust patients have in us to give our full effort.
if the patient is unable to say what his/her wishes are?
In some cases, the decision about CPR occurs at a time when the patient is
unable to participate in decision making, and hence cannot voice a preference.
There are two general approaches to this dilemma: Advance
Directives and surrogate decision makers.
Directive: This is a document which indicates with some specificity
the kinds of decisions the patient would like made should he be unable
to participate. In some cases, the document may spell out specific decisions
(e.g. Living Will), while in others it will designate
a specific person to make health care decisions for them (i.e. Durable
Power of Attorney for Health Care). There is some controversy
over how literally living wills should be interpreted. In some cases,
the document may have been drafted in the distant past, and the patient's
views may have changed. Similarly, some patients do change their minds
about end-of-life decisions when they actually face them. In general,
preferences expressed in a living will are most compelling when they reflect
long held, consistently stable views of the patient. This can often be
determined by conversations with family members, close friends, or health
care providers with long term relationships with the patient.
decision maker: In the absence of a written document, people
close to the patient and familiar with his wishes may be very helpful.
The law recognizes a hierarchy of family relationships in determining
which family member should be the official "spokesperson," though generally
all close family members and significant others should be involved in
the discussion and reach some consensus. The hierarchy is as follows:
Legal guardian with health care decision-making authority
Individual given durable power of attorney for health care decisions
Adult children of patient (all in agreement)
Parents of patient
Adult siblings of patient (all in agreement)