Practical Guidelines for Do-Not-Resuscitate Orders
Practical Guidelines for Do-Not-Resuscitate Orders
By: Mark H. Ebell
Source: Mark H. Ebell. "Practical Guidelines for Do-Not-Resuscitate Orders." American Family Physician 50 (November 1, 1994).
About the Author: Mark H. Ebell is a physician who has practiced in Athens, Georgia, held a faculty position at Michigan State University College of Human Medicine, and has contributed several articles to American Family Physician. He also has written a number of "handheld" clinical guides for different medical topics and recently edited a book concerned with the use of handheld computers in the practice of medicine.
Do not resuscitate (DNR) orders, along with medical advance directives, are designed to empower patients who are unlikely to derive long-lasting benefits from the use of extraordinary life-saving measures. Simply put, they allow patients to choose not to have CPR or other resuscitative measures if their heart or breathing should stop. If there is no DNR physician's order present in a hospitalized patient's medical chart, the medical staff is bound (by medical and legal regulations, as well as professional ethical standards) to employ CPR, mechanical ventilation, and other life-saving techniques and equipment in the event of cardiac or respiratory failure. Several decades of research have shown that, for people who are critically or terminally ill, there is not always substantial recovery or quality of life benefit gained after cardiac cessation and prolonged resuscitation efforts.
During the 1960s and 1970s, there were relatively few decisions to be made in the care of terminally ill patients, as there was no real technology available to prolong life in the event of multiple organ or system failure. A simple order prohibiting the use of CPR was generally sufficient during that era. By the end of the twentieth century, life-sustaining technologies had reached such sophistication that the decisions had become far more complicated. They concerned not only CPR, but also in-dwelling nasal or gastric feeding tubes, prolonged intubation or the use of tracheotomy for the purposes of maintaining mechanical ventilation, ongoing mechanical suction to prevent choking on oral and nasal secretions, and the type and degree of cardiac resuscitation tools to be used in the event the heart stopped beating. In addition to those more mechanical process decisions, an entire gamut of other ethical issues arose. How far does a medical team go in order to prolong the life of a terminally ill patient? Where does one draw the line at attempting or continuing chemotherapy or radiation, or attempting surgery?
As medical technology has expanded exponentially, the educational level of patients also has increased. Many individuals now use the Internet to educate themselves about a wide range of health and disease topics. For the first time, patients are able to use outside sources and do not have to rely solely upon their own physicians or medical care providers for information. They can obtain realistic, real-time, cutting-edge data regarding the likely prognosis of their disease, as well as a comprehensive listing of the location, availability, and likelihood of positive outcomes with experimental or nontraditional interventions. Patients now have the ability to access information that allows them to make informed choices—both to direct their care and to plan their own end-of-life processes through the use of palliative care and pain control measures.
Do-not-resuscitate (DNR) orders are directives in the medical record that preclude the use of resuscitative measures such as chest compressions, artificial respiration, cardioversion and/or cardioactive medications in the event of cardiopulmonary arrest. DNR orders are widely used in the United States, with studies showing that the majority of hospitalized patients who die have had a DNR order written.
Because of the wide application of DNR orders, it is important that physicians understand the ethical, legal and medical implications of these documents. This article summarizes the historic background and ethical rationale for DNR orders and describes laws and policies regarding DNR orders in the context of their implications for clinical practice. This article also provides practical guidelines for the use of DNR orders, including specific information regarding prognosis, to help physicians carry out discussions with patients and families.
Like many medical technologies, cardiopulmonary resuscitation (CPR) became the standard of care without careful consideration of its effectiveness in different patient populations. Kouwenhoven and colleagues, first described the technique in 1960; they reported a 70 percent survival rate in a small group of perioperative patients. As experience with the technique grew and CPR was applied to other patient populations, it became clear that only a minority of patients who had CPR survived to hospital discharge. Also, resuscitative attempts in patients who had a period of hypoxia sometimes resulted in the loss of higher cortical function but the preservation of brainstem function, leaving patients in a vegetative state for varying amounts of time. Physicians became increasingly concerned that they could be doing harm to some patients by attempting resuscitation in all patients.
During this same period, patients were demanding an increased role in medical decision-making. This need was rooted in a rising awareness of individual rights and in dissatisfaction with the traditional paternalistic model of the physician-patient relationship. Thus, a desire to conform to the ethical principles of nonmalfeasance (not doing harm) and autonomy (the right of self-determination) resulted in the development and increased use of DNR orders….
The most recent policy statement by the Council of Ethical and judicial Affairs of the American Medical Association supports the use of DNR orders and identifies futility and patient preference as the two primary reasons to withhold CPR. In addition, the joint Commission on Accreditation of Health Care Organizations requires that all acute care facilities have a formal institutional policy regarding advance directives and DNR orders. Finally, institutions must have a survey process that ensures compliance.
Specific types of DNR policies include recognition of only a single "no code" or "do-not-resuscitate" designation, as well as more comprehensive policies that recognize varying levels of care. The latter are preferable, since they allow physicians to tailor the DNR order to fit the patient's specific needs. It has been suggested that "do not attempt resuscitation" may be a more appropriate term than "do not resuscitate," especially given the low rate of survival in some patient populations. Also, the term "comfort-oriented care" is used by some facilities, since it reminds caregivers that for many terminally ill patients, fear of pain and abandonment are very important factors in a patient's decision to request resuscitation….
Rationales for Writing DNR Order A number of rationales have been proposed for the use of DNR orders. These rationales include patient preference for any reason, poor quality of life before CPR, a perception that the burden of care imposed by the CPR process outweighs the benefit, the cost of medical care, religious preference and previous personal experience.
Although still somewhat controversial, a consensus is emerging that physicians may write a DNR order for a patient if they believe that resuscitation would be futile. In its statement on DNR orders, the Council on Ethical and judicial Affairs of the American Medical Association states that "when efforts to resuscitate a patient are judged by the treating physician to be futile, even if previously requested by the patient, CPR may be withheld. In such circumstances, when there is adequate time to do so, the physician should inform the patient or the incompetent patient's surrogate of the content of the DNR order, as well as the basis for its implementation, prior to entering a DNR order into the patient's record." In such a case, the physician should inform the patient or appropriate surrogate decision-maker of the decision and provide the opportunity for transfer of care if a conflict arises.
Timing of Discussion About DNR Order Most patients have discussed issues of resuscitation with their families and would like to discuss these concerns with their physician. However, only 10 percent of patients have discussed their wishes regarding CPR with a physician. Also, while approximately 75 percent of patients who receive a DNR order are impaired at the time that it is written, only 10 percent are impaired at the time of admission to the hospital. Thus, most patients are not given the opportunity to participate in discussions about their own resuscitation, although they would like to do so….
Patients for Whom DNR Orders Should Be Addressed in the Outpatient Setting or Early in Hospitalization:
Patients with any terminal illness
Patients who may be considered to have a poor quality of life
Patients who may have an illness or disabling condition that is severe and irreversible
Patients who are at increased risk for cardiac or respiratory arrest
Patients who have suffered an irreversible loss of consciousness
Patients who are unlikely to benefit from CPR based on a single factor such as metastatic cancer, or a combination of factors such as sepsis and impaired renal function or advanced age and pneumonia
Patients in whom there is some reason to question the presumption of consent for CPR
(Adapted from "Guidelines on Cardiopulmonary Resuscitation" from the Hastings Center.)
Many approaches may be taken to initiating discussion about DNR orders, depending on the physician's individual style. It is often helpful to begin the conversation with a qualifying remark such as, "I routinely discuss CPR with my patients who are in the hospital. Do you know what CPR is?" The depiction of CPR in the mass media has resulted in significant misconceptions among patients about the length, intensity and possible outcomes of the CPR process. In order that patients give truly informed consent, it may therefore be necessary to describe the process in some detail.
It is also important to emphasize that DNR orders are a mechanism for expressing the patient's wishes for medical care. A physician could open the discussion by saying, "I think it is important to talk about (CPR, resuscitation, endotracheal intubation) because I want to make sure that I know what kind of medical treatment you want when you are not able to talk to me or tell me your opinion." Patients may respond by putting the decision-making burden on someone else, with a statement such as "Whatever you think, doc," or "Just talk to my family." If this happens, it is important that the physician reemphasize to the patient that it is the patient's opinion that is most important, while understanding that some patients may be more comfortable with a more paternalistic model of care.
Providing Prognostic Information When discussing DNR orders with patients, it is helpful to provide concrete prognostic information. Just under one-half of patients survive the code itself, even if only for a long enough period to be transferred to the intensive care unit; one-third survive for 24 hours, and approximately one-eighth survive to hospital discharge. In the most careful follow-up study to date, approximately 30 percent of patients who survived to discharge after CPR suffered a significant increase in dependence, requiring either extensive home care or institutionalization. A smaller percentage, approximately 2 to 5 percent, have severe mental impairment….
Involving Others in the Decision-Making Process If a conflict exists, or if a patient indicates a desire to discuss issues regarding resuscitation with family members, a family meeting may be an appropriate forum for discussion. Although most patients place the greatest value on the input of their spouse, physician and children, it is best to ask the patient exactly who should attend a discussion about DNR orders. It may be appropriate in some instances to include lovers, life companions, ministers, social workers and nursing staff.
In such a meeting, the physician serves as facilitator….
The appropriate use of DNR orders is an important way to prevent unnecessary suffering and the misallocation of scarce medical resources. Most patients will welcome an open and caring discussion of their alternatives regarding resuscitation with a physician who is prepared to discuss these issues.
The concept of medical choice regarding the ending of an individual's life is relatively novel and has been fraught with ethical concerns for physicians and other senior health care providers. The American Medical Association's Council on Ethical and Judicial Affairs has smoothed the way considerably, and their guidelines have offered physicians a measure of ethical assurance and comfort, which should permit them to work in partnership with their patients in order to facilitate informed and well-considered individual choices about end-of-life care.
In the past, patients have frequently not been offered the full range of information that could impact their decision-making, when they still possessed sufficient mental clarity to be able to make good use of the data. Patients were often encouraged by well-meaning family members and caregivers to "fight to the end," rather than to make an informed choice to use only palliative (comfort) care or to stop treatments that might negatively impact their quality of life near the end. Not infrequently, family members historically chose to hide the truth of a terminal diagnosis from their loved ones—particularly if the dying person was elderly or a child—out of a belief that this was a kind thing to do. The paradigm has shifted dramatically, and children and older adults are now being given honest information, as well as some say in the direction of their care, on a more frequent basis. Increasingly, patients (and significant others in their lives) are demanding the right to be knowledgeable members of the treatment planning team, and are afforded more opportunities to direct their own care, when those requests are reasonable and economically feasible. The key, for all concerned, is to have the physician or treatment team leader give the patient understandable and objective information, delivered in a sensitive and respectful manner, at a time that the patient is not too ill to be able to hear it. Ideally, the conversation should be initiated well before the patient needs to be in an inpatient setting. Medical schools and hospital programs are increasingly providing training for physicians in the art of initiating conversations with their patients about resuscitation efforts and advanced directives.
From the standpoint of the larger health care system, this is not only the most reasonable course, it is the most economically feasible, since the number of heroic and often unsuccessful (but very costly) treatments undertaken is likely to be considerably limited. Typically, the most extraordinary measures are also among the most expensive—and third-party payers (such as insurance companies) are not always as quick to either authorize or reimburse when the patient is terminally ill, moribund, or deceased. In addition, there are far fewer legal ramifications for all concerned if the patient is able to be an active participant in the end-of-life care plan, rather than leaving the treatment team with the responsibility for making those types of decisions under duress and in highly stressful and emotionally charged circumstances.
When patients are allowed and encouraged to be active participants in the care given at the end of their lives, they are able to make choices that allow them to increase the quality of their remaining time with loved ones, complete unfinished business, effectively control pain, and exert significant control over the timing and manner of their death. They can help to choose the methods by which their symptoms are managed, the manner in which they receive nutrition (or not), and elect not to have the disease progression altered at the end. The concept of the Do-Not-Resuscitate order allows patients to die with a far greater degree of dignity, with much less stress, and in a far more natural manner with the assistance of knowledge and ever-advancing technology.
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