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.
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.
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
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.
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 or she does not want CPR, should the need arise.
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.
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:
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
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
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.
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
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
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
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.
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.
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.
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.
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:
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)