What if CPR is not futile, but the patient wants a DNR order?
What if the patient is unable to say what his/her wishes are?
As 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.
Like 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.
When 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 cardiac rhythm.
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.
When 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:
when CPR is judged to be of no medical benefit (also known as "medical futility"; see below), and
when 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.
When 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.
When 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:
Septic shock
Acute stroke
Metastatic cancer
Severe pneumonia
In other clinical situations, survival from CPR is extremely limited:
Hypotension (2% survival)
Renal failure (3%)
AIDS (2%)
Homebound lifestyle (4%)
Age greater than 70 (4% survival to discharge from hospital)
How 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.
If 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.
In 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.
What 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 treatment.
What 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 patient/family agreement.
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 futile.
What 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.
What 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.
Advance 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.
Surrogate 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
Spouse
Adult children of patient (all in agreement)
Parents of patient
Adult siblings of patient (all in agreement)