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Industry: Email Alert RSS FeedPractical guidelines for do-not-resuscitate orders
American Family Physician, Nov 1, 1994 by Mark H. Ebell
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]
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.[8] 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.
A facility may make other types of care contingent on the existence of a DNR order. For example, some extended care facilities may not transport patients with a DNR order to the hospital, while some hospitals may not allow patients with DNR orders to be cared for in the intensive care unit. Such practices are ethically questionable. Since most patients who have had a DNR order written are not appropriate candidates for intensive care, the decision about resuscitation should remain distinct from other medical decisions.
Some physicians still order "show codes" or "slow codes," in which a unilateral decision is made to provide only a half-hearted attempt at resuscitation, in order to avoid a discussion about resuscitation with the patient or family. Such a practice is dishonest and unethical and should be strongly discouraged.[10] In addition, it exposes the physician to liability risk, since a significant medical decision is made without consulting the patient or the surrogate decision-maker. On the other hand, "chemical codes" in which only cardioactive medications are given, "do-not-intubate" orders and other forms of restricted codes may be ethically and medically appropriate for carefully selected patients. As with any DNR order, these orders should be discussed with patients or their designated decision-makers, and the decision should be carefully documented in the medical record.
Practical Guidelines for
DNR Order Discussions
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.[11,12]
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