Some patients and their families find themselves wanting to talk with their doctors about ensuring that a "Do-Not-Resuscitate" or DNR order is written in their charts. There are even those who consider buying bracelets which express this sentiment, stating their wishes clearly to anyone who might read the engaved words. What all of this entails is a patient stating in advance whether he or she wantss to or doesn't want resuscitation following a cardiac arrest or life-threatening arrhythmia. Many patients fear losing control in such a situation, that with resuscitation they may find themselves being kept alive in a physical state with a lessened quality of life and no way out.
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 likelihood for clinical benefit, the patient's preferences regarding intervention, and the outcome that's likely to result. Decisions to forego cardiac resuscitation are often difficult because of real or perceived differences in these considerations. Patients are not always aware that resuscitation does not always have to result in a reduced quality of life or being unable to do anything about the situation later on. As a result, it is useful for every patient considering a "Do-Not-Resuscitate" or DNR order to talk about their desires and fears with their family members and physician. (See Advance Care Planning.) It also is of vital importance to prepare a written document, either a Living Will or other Advance Directive, which clearly reflects their philosophy and goals for possible future medical interventions. Such documents can prevent unwanted interventions and ensure that the patient's wishes are upheld.
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.
As a patient, you need to know that should you stop breathing or if your 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 usually required to administer CPR.
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 or she does not want CPR, should the need arise.
When is CPR "futile"?
CPR is "futile" when it offers no clinical benefit. When CPR offers no benefit, your physician is ethically justified to withhold 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%)
You might consider these success rates, your own physical condition, and your desires regarding quality of life in determining how you would like to procceed in talking with your physician about a possible DNR order
How should quality of life be considered?
CPR might also seem to lack benefit when your quality of life is so poor that no meaningful survival is expected even if CPR were successful at restoring circulatory stability. Only you can judge your "quality of life," especially if you experience a chronic illness. Be aware, however, that your own feelings about future quality of life may very well change as your life experience and physical health changes, especially if you are presently healthy and active. In this regard, there is substantial evidence that patients with such chronic conditions often rate their quality of life much higher than healthy people judge them. 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 your physician is under no obligation to provide it. Nevertheless, either you as the patient or your family should 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, a patient or his or her 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
What if CPR is not futile, but you want 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 him or her. If you understands your condition and possess intact decision making capacity, your 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 hospitals, 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. For this reason it is quite helful if you have a prepared Advance Directive of some form, especially one that names an agent or surrogate decision maker to act on your behalf.
What about "slow codes"?
It is the policy of most hospitals 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 you might be 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 you would like made should you 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 you (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 your 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 your long held, consistently stable views. This can often be determined by conversations you may have had with family members, close friends, or health care providers with whom you have had long term relationships.
Surrogate decision maker: In the absence of a written document, people close to you, who are familiar with your 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: