Transcript Slide 3 Ethics: DNR Decisions TNEEL-NE

Sarah E. Shannon, PhD, RN
Ethics: DNR Decisions
History of CPR & DNR Orders
• The “Birth” of CPR
– First study in 1960 found 80%
success rate.
– Consent presumed.
• AMA call for written DNR
orders by 1974.
• Defining 1976 events:
– Karen Ann Quinlan Supreme Court ruling.
– Massachusetts General and Beth Israel Hospital formal guidelines
published.
– First Natural Death Act passed in California.
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Ethics: DNR Decisions
Current Status of CPR &
DNR Orders
• More recent studies show success rates
for in-hospital CPR of 19%-57%.
• DNR, Code Blue, DNAR orders, etc.
are more common.
• 1995 Study: Only 13% of hospitalized
patients have CPR attempted at time of
death.
• Success rates of in-hospital CPR will
increase as number of attempts drop.
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Ethics: DNR Decisions
CPR: Legal and Ethical Issues
Does CPR require consent?
Can a patient refuse CPR?
Is CPR a treatment or a right?
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Ethics: DNR Decisions
Legal Basis for Performing
or Withholding CPR
• CPR falls between the cracks in terms of anticipated
treatment for which we would obtain informed consent and
emergency treatment where informed consent is presumed.
• Obtaining informed consent necessitates dialog about
death and dying which may be difficult for providers,
patients and surrogates.
• DNR orders are generally regulated by informed consent
legislation, but patient preferences (as in an advance
directive) may also need to be considered.
• CPR performed against a patient’s wishes can potentially
result in legal problems for providers.
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Ethics: DNR Decisions
Current Issues: DNAR Orders
• Many institutions are now using the term
Do-Not-Attempt-Resuscitation (DNAR)
instead of Do-Not-Resuscitate (DNR)
The word “Attempt” is intended to
emphasize that CPR is often not successful
X
DNR
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DNAR
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Ethics: DNR Decisions
Current Issues:
“Slow Codes” Definition I
Not responding efficiently or
urgently to a code situation thus
“going through the motions,” but
without meeting the standard of
care for resuscitation attempts.
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Ethics: DNR Decisions
Current Issues:
“Show Codes” Definition II
Rapidly responding to a code
situation but not aggressively
pursuing resuscitation efforts thus
not meeting the standard of care
for resuscitation attempts.
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Ethics: DNR Decisions
Current Issues:
“Slow Codes” & “Show Codes”
• Reasons why “Slow Codes” or “Show Codes”
exist:
– Providers don’t wish to discuss withholding CPR with a
patient or legal surrogate due to cultural, racial, religious,
or other differences.
– Providers have been unsuccessful in obtaining agreement
from the patient or the family to withhold CPR.
Both codes are unethical and represent fraud because
typically institutions bill the patient or insurance carrier.
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Ethics: DNR Decisions
Current Issues: Futility
• What if health care professionals believe
CPR would be futile?
• Is CPR a medical treatment or a right?
• Do patients or their families have the right
to demand CPR even if medical opinion is
that it would not be successful,
or produce the desired benefit?
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Ethics: DNR Decisions
Current Issues:
Quantitative Futility Definition
Where research suggests that a
therapy will have a less than 1%
chance of producing the desired
physiological effect;
e.g. with CPR, of restoring
cardiac function.
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Ethics: DNR Decisions
Current Issues:
Qualitative Futility Definition
Where personal, professional, or public opinion
suggests that while a therapy can achieve a desired
effect, it will not produce the desired benefit.
e.g., a situation such as persistent vegetative state
(PVS) where CPR is expected to be successful in
restoring cardiac function, but the individual will
not and cannot regain neurological function or
meaningful consciousness.
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Ethics: DNR Decisions
Current Issues:
“Portable” DNR Orders I
• About half the US states have legislation providing for
out-of-hospital or "portable" DNR orders.
• Portable DNR orders allow EMS personnel to not start
CPR, but allow them to provide . . .
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assessment
assistance with choking including airway clearance
oxygen and medications for dyspnea
aggressive pain management
grief counseling
other appropriate services to patient and family
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Ethics: DNR Decisions
Current Issues:
“Portable” DNR Orders II
• Some states limit to only terminal or elderly
patients, others allow for any competent adult.
• Both the health care provider’s signature and
the patient’s or surrogate’s signature is
required.
• Patients receive a copy of the original order
and also some form of wearable identification.
• Most states allow EMS personnel to by-pass
the DNR order if the patient’s family strongly
insists.
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Ethics: DNR Decisions
Current Issues:
“Portable” DNR Orders III
• Ideally the provisions and expectations of a portable
DNR order are discussed in an in-patient setting.
• Many states are working to make the portable DNR
order the standard for nursing homes and other
community-based care facilities so that medics who
respond to calls in those facilities can honor them.
• A portable DNR order is not an advance directive. It
is a physicians order to withhold a therapy and
requires the patient’s signature as proof of informed
consent.
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Ethics: DNR Decisions
Systems Issues I
• Policies that protect a patient’s right to accept or
refuse CPR should be written to include provision for:
– DNR orders to follow patients across settings/services.
– Patients or legal surrogates to be informed when a DNR
order is written.
– An appeal process in case the physician in charge is
unwilling to write the DNR order.
– Policies that recognize portable or community-based
DNR orders in specific situations or settings.
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Ethics: DNR Decisions
Systems Issues II
• Hospital policies should allow patients or their
surrogates to refuse CPR even in the absence of a
written or verbal order from a physician, in cases
where:
– The patient or their surrogate clearly refuse CPR.
– The provider has no evidence to suggest that the request
is not made in good faith.
– The physician cannot be reached or refuses to write a
formal DNR order in spite of the patient’s or surrogate’s
wishes.
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Ethics: DNR Decisions
Systems Issues III
Although situations like these are
rare, if CPR is administered in
spite of a patient’s clear refusal, it
may constitute assault and/or
battery.
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Ethics: DNR Decisions
Patient Care Scenarios
Types of Patients with DNR orders
• The Classic Scenario
• The Critical Care Scenario
• The Patient Autonomy Scenario
• Community-based or
Portable DNR Scenario
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Ethics: DNR Decisions
The Classic Scenario I
The “Comfort Care Only” patient
• Death is anticipated
• Goal: Alleviate suffering
• CPR and other treatments withheld
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Ethics: DNR Decisions
The Classic Scenario II
The “Comfort Care Only” patient
• DNAR does NOT mean "no care"
• DNAR, not abandonment
• CPR may or may not be futile
Mr. Williams
• Family members ask if signing a
DNR means the nurse and hospital
are giving up on their father
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Ethics: DNR Decisions
The Critical Care Scenario I
The “Do Everything BUT CPR” patient
• Reasonable hope of recovery
• Goal: Prolonging life, etc.
• CPR withheld, but nothing else
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Ethics: DNR Decisions
The Critical Care Scenario II
The “Do Everything BUT CPR” patient
• Need to reassess situation often
• DNAR, not "slow care”
• CPR may or may NOT be futile
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Ethics: DNR Decisions
The Patient Autonomy Scenario I
The “Do Only What I Wish” patient
• Death may or may not be expected even in
the near future
• Goal: Will vary with patient
• CPR is not wanted
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Ethics: DNR Decisions
The Patient Autonomy Scenario II
The “Do Only What I Wish” patient
• “No CPR" means ONLY “No CPR”
• Need to clarify patient's wishes
• CPR may or may not be futile
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Ethics: DNR Decisions
Community-based or
Portable DNR Scenario I
The “Help Me but Don’t Save Me” patient
• Death may or may not be expected even in
the near future
• Goal: Will vary
with patient
• CPR is not wanted
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Ethics: DNR Decisions
Community-based or
Portable DNR Scenario II
The “Help Me but Don’t Save Me” patient
• Requires signature of patient or patient’s
surrogate and physician
• “No CPR" means
ONLY “No CPR”
• Need to clarify
patient's wishes
• CPR may or may
not be futile
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