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Excerpt
Most if not all physicians have to deal with do-not-resuscitate (DNR) orders at some stage during their practice. Approximately 40% to 65% of intensive care unit (ICU) deaths have been preceded by decisions to withhold or withdraw life support [1,2]. In ancient Greece, Hippocratic Corpus stated that one of the primary roles of medicine was to refrain from treating hopelessly ill persons, lest physicians be thought of as charlatans [3].
Cardiopulmonary resuscitation (CPR) is controversial because it can lead to prolonged suffering or an undignified death. One study showed that physicians largely ignored or were unaware of the desire of terminally ill patients to be designated as DNR [4]. In contrast, it has been shown that patients wish to discuss DNR status with their physicians [5]. The consensus favors physicians having the privilege to decide to limit care, even against the wishes of the patient or the patient's surrogate. Various hospitals have instituted policies allowing physicians to write unilateral DNR orders. The article in this issue of Critical Care Medicine by Casarett and Siegler [6] looked at 31 ethics consultations regarding unilateral DNR orders written during a 4-yr period. In 17 cases, the disagreement between physicians and the patient or surrogate over code status was resolved in a conference organized by the ethics service, and unilateral DNR orders were written in only seven cases. This article raises important points about DNR orders.
This study appears to validate the Houston Task Force approach, which advises a procedural model for resolving DNR disputes and encourages interdisciplinary participation in decision-making [7]. The Houston Task Force approach is discussed in detail later. Thus far, none of the 31 patients in the above series, or their estates, has made a legal claim against the hospital for any reason. Most of the patients were in an ICU at the time of consultation. Ethics consultants believed that only four of 31 patients had decision-making capacity at the time of consultation. Some of these disputes would have been avoided if DNR status discussions had taken place before admission or early after admission. ICU admission may be an inappropriately late point for DNR discussions, because patients are often incompetent.
One weakness in the Casarett and Siegler study is that it is retrospective. Ideally, an intervention such as an ethics consultation should be tested in a prospective manner. Of note, when consensus was reached by means of a family conference organized by the ethics team, it was always to limit treatment. This raises legitimate concerns about the possibility of coercion.
A series of important questions emerges from the discussion by the authors. How should futility be defined? When is it appropriate to write a DNR order? What are the survival figures from cardiac arrest? Are patients given realistic survival information? Do unrealistic expectations by the general public contribute to disagreements over end-of-life issues? Do unilateral DNR orders impair patient/surrogate autonomy? Should there be provision for a patient's right to transfer care? Do advance directives help avoid controversy over DNR orders? Are physicians exposing themselves to litigation risk by writing unilateral DNR orders, even when institutional approval exists? Is there ready access to an ethics team? Does scarcity of resources have any role in futility decisions?
Recommendations regarding DNR issues in the medical literature have come from many sources, including the American Medical Association (AMA) [8], the Society of Critical Care Medicine (SCCM) [9], the President's Commission Report from 1983 [10], and, recently, the Houston Task Force [7]. Some but not all of the above questions are addressed in these articles.
