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Practical guidelines for do-not-resuscitate orders - includes patient information sheet

American Family Physician, Nov 1, 1994 by Mark H. Ebell

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.[1,2]

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.

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Background

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,[3] 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.

Legal Issues

The right of a competent patient or a designated, appropriate surrogate decision-maker to refuse any kind of medical treatment, including life-sustaining therapy, has been well established[4] In every case that has questioned the legality of DNR orders, the court has upheld their legality, even in the absence of specific legislation addressing their use.[5] Nevertheless, some physicians may still hesitate to write a DNR order because of a fear of legal action. Such fears have little basis in legal precedent.

Two states (New York and Georgia) have enacted statutes that specifically address the use of DNR orders. These laws provide physicians with a "safe harbor" that protects them from lawsuits or prosecution if they issue DNR orders in accordance with the guidelines provided by the statute. An algorithm that illustrates the key points of both laws is shown in Figure 1. Although designed with these states, particular statutes in mind, it can provide a useful guide for physicians writing DNR orders in other states as well.[5]

The Patient Self-determination Act (PSDA), an amendment to the federal Medicare and Medicaid laws, was enacted in 1990.[60] By requiring that patients be advised of their right to accept or refuse medical treatment at the time of admission to a nursing home or an acute care facility, the amendment may enhance patient awareness of DNR orders. However, the overall impact of the act on DNR decision-making remains uncertain and will depend on the method of implementation by hospitals and nursing homes.

The actions of a retired pathologist, Jack Kevorkian, M.D., have resulted in the passage of a Michigan law that addresses the issue of physician-assisted suicide. The law set penalties for individuals who "provide the physical means by which the other person attempts or commits suicide" or who "participate in a physical act by which the other person attempts or commits suicide."[7] In June of 1994, the Michigan Court of Appeals struck down the law; however, the Michigan Supreme Court ordered that the law remain in effect while the case is being heard. Dr. Kevorkian was recently acquitted of one charge related to assisting a patient's suicide, although he still may face charges in other jurisdictions.

In addition to the Michigan law, about three dozen states have outlawed assisted suicide. Ballot initiatives to allow assisted suicide for terminally ill patients have been defeated by voters in California, Washington and Michigan.

It should be noted that this law is only intended to address the issue of assisted suicide and should not have any effect on the use of DNR orders.

Policy Issues

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.[8] 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.[9]

Health Care Industry

Practical guidelines for do-not-resuscitate orders - includes patient information sheet

American Family Physician, Nov 1, 1994 by Mark H. Ebell

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