I.Orders to Withhold Cardiopulmonary Resuscitation

TNEEL-NE

DNR Decisions

Student Handout/ Content

I.Orders to Withhold Cardiopulmonary Resuscitation

History of CPR and do-not-resuscitate (DNR) orders

1.CPR first reported in 1960 with success rate of 80%.1

2.Patient consent to CPR was initially presumed similar to consent to other emergency care.2

3.By 1974, the AMA called for written DNR orders

4.Three events occurred in 1976 to change the view that CPR should routinely be attempted at the time of death.

Supreme Court of New Jersey ruled that Karen Ann Quinlan could have mechanical ventilation withdrawn;
Massachusetts General Hospital and Beth Israel Hospital published formal guidelines on limiting treatment at the end of life; and
California passed the first Natural Death Act.

II.Current Status

A.Success Rates and Utilization

1.Multiple studies have found in-hospital CPR success rates of 19% to 57% with only 4% to 24% of patients who receive CPR discharged alive.3-5

2.Many factors led to widespread use of DNR orders to avoid needless, useless or futile resuscitation at the time of death.

3.A large multi-site study found that only 13% of patients who were hospitalized had resuscitation attempted at time of death.6

4.As the number of "attempts" decrease, it is important to realize that the "success" rates of in-hospital CPR will increase.

B.Legal Basis for Performing or Withholding CPR

1.CPR falls between cracks in terms of anticipated treatment for which we would obtain informed consent and emergency treatment where informed consent is presumed.

2.Obtaining informed consent for CPR necessitates a discussion about death and dying which may be difficult for healthcare professionals and patients or their surrogates to have.

3.DNR orders fall under the informed consent legislation generally but MAY be informed by the patient's previously stated preferences such as in an advance directive.

4.CPR which is performed against the patient’s or family’s expressed wishes can result in charges of assault and battery, malpractice or both for providing an unwanted therapy. Two recent suits brought by families were successful initially and now are being reviewed by appellate courts.

C.Current Issues

1.DNAR Orders

Recently, many institutions have changed the name of no-code orders from do-not-resuscitate orders to do-not-ATTEMPT-resuscitation orders. The word attempt is intended to emphasize that CPR is often not successful.

2.“Slow” Codes and “Show” Codes

i.Slow codes: healthcare providers do not respond efficiently or urgently to a code situation thus “going through the motions” but without meeting the standard of care for resuscitation attempts.

ii.Show codes: healthcare providers rapidly respond to a code situation but do not aggressively pursue resuscitation efforts such as through ineffective or brief chest compressions, knowingly using IV lines that are not patent, etc. Again the standard of care for resuscitation is not met.

iii.Both slow codes and show codes are unethical. They represent fraud because typically institutions bill the patient or an insurance carrier.

iv.Slow codes or show codes may be utilized by healthcare professionals for several reasons:

Because they do not wish to discuss withholding CPR with a patient or the legal surrogate due to cultural, racial, religious or other differences.
Because they have been unsuccessful in obtaining agreement from the patient or the family to withhold CPR.

3.Futility

What if healthcare 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 is not indicated because it would not be successful (that is, it would have a very low probability of producing the desired effect of restoring organ function = quantitative futility).

i.Quantitative futility: 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.7, 8

ii.Qualitative futility: 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 in which CPR is expected to successfully restore cardiac function but the individual will not and cannot regain neurological function or meaningful consciousness.8

4.“Portable”, Community-based, or Out-of-hospital DNR Orders

i.About half the fifty states have passed legislation allowing for out-of-hospital or “portable” DNR orders.

ii.If person with a portable DNR order should arrest, and emergency medical personnel respond, the EMS personnel are allowed to not initiate CPR but can provide

-assessment

-assistance with choking including airway clearance

-oxygen for dyspnea

-pain management,

-grief counseling

-other appropriate services to the patient and family.

iii.Some states limit access to portable DNR orders to patients who are terminal or elderly while some states allow access to any competent adult.

iv.Portable DNR orders require both the physician’s signature (or in some states, a Nurse Practitioner) and the patient’s or surrogate’s signature.

v.Patients receive two forms of “proof” of this order - a copy of the original order form and a form of “wearable” identification such as a medic alert bracelet.

vi.Most states include a provision allowing EMS personnel to perform CPR if the family persistently and strongly requests it even if the person has a portable DNR order but EMS personnel are trained to counsel families in these difficult situations to forgo CPR.

vii.Hospitals, clinics and other healthcare systems need to have a policy that discusses the circumstances under which community-based DNR orders will be honored. In particular, policies should address care of the person with a portable DNR order in the emergency room, in the clinic setting, on admission to the hospital, etc. In addition, consideration of the need or desire for a portable DNR order should be part of the nursing discharge assessment for every hospitalized patient.

viii.Many states are working to make the portable DNR order the standard for nursing homes and other community-based care facilities so that medics responding to calls in those facilities can honor the institutional-based order regarding CPR for the person.

ix.A portable DNR order is NOT an advance directive. It is a physician’s order to withhold a therapy and requires a patient or surrogate signature as evidence that informed consent occurred, similar to consent for a surgical procedure.

Example:
Please enter your state law regarding portable DNR orders below. You can find information using the State Code Table from TNEEL-NE program.

D.Systems Issues

1.Hospitals, other institutions and community-based services should have written policies to protect patients’ rights to accept or refuse CPR in advance of an arrest. These policies should include mechanisms to insure that:

DNR orders follow the patient across settings and services.
Patients or their legal surrogates are informed when a DNR order is written.
Patients and surrogates who request a DNR order have a mechanism to appeal if the physician in charge is unwilling to write the order.

2.Policies should also address community-based DNR orders (see above under current issues: portable DNR orders).

3.Hospital policies should also allow patients or their surrogates to have their right to refuse CPR honored even in the absence of a written or verbal order from a physician to withhold CPR. For example, the nurse or a supervisor should be able to authorize DNR status in situations where:

the patient or surrogate clearly refuse CPR in the event of an arrest;
the nurse has no evidence to suggest that this request is not made in good faith (e.g., that the person speaking for the patient is not the valid surrogate); and
the physician cannot be reached to obtain a formal DNR order or the physician refuses to write such an order in spite of the patient’s or surrogate’s lack of consent for CPR procedures.

4.Although these or similar situations are rare, if CPR is administered in spite of a patient's clear refusal to consent to the therapy, it may constitute assault, battery or both on the part of the healthcare professional. Institutional policy should address these rare circumstances to insure that patients do not receive unwanted therapies and that healthcare professionals are not placed in a situation where they must choose between placing themselves at legal or professional risk versus administrative or institutional risk. Some considerations for these policies include but are not limited to:

Requiring that nurses, respiratory therapists, and other non-MD healthcare personnel get witnesses and document the patient's refusal of CPR in the chart
Initiating vigorous efforts to contact the physician and other appropriate supervisory personnel but ensure that the patient is not subjected to CPR if she/he arrests prior to the order change.
Allowing documented refusals of life-supportive therapies by competent patients to be honored should that patient become incompetent, even in cases in which families insist on providing them.

III.Nursing Implications of a DNR Order

A.The Classic Scenario: The “Comfort-Care Only” Patient

1.Features

1.Death is anticipated this hospitalization or soon after discharge.

2.The medical goal of care has switched from one of treating the disease in hopes of prolonging life or "cure" to one of alleviating suffering and not prolonging the dying process.

3.Therapies have been limited to those that promote comfort. In particular, diagnostic testing and treatment of deteriorating physiological function is being withheld or withdrawn.

4.CPR is one of many emergency therapies being withheld. The process of withdrawing curative therapies often start with a DNR order, followed in quick succession by a withdrawal of other life-sustaining therapies such as mechanical ventilation, blood transfusions, etc.

5.Nursing personnel are typically most familiar and comfortable with patients represented by this scenario.

2.Concerns

1.Comfort-Care Only DOES NOT mean that a patient should have nutrition and hydration, treatment of yeast infections, symptom management such as treatment of fever, or pain management routinely withheld or withdrawn. There continues to be well-documented evidence that at least half of conscious dying persons experience moderate to severe pain in the last three days of life.6 More disturbingly in the face of such dismal findings, nurses do a better job at pain management than at treating other sources of suffering such as dyspnea, thirst, hunger, itching, anxiety, etc.

2.Comfort-Care Only should not constitute an abandonment of the patient and/or family.6

3.CPR itself may not be futile but the condition or prognosis is futile in that physical deterioration cannot be reversed or that the reversal is not desired by the patient or, in the case of a mentally incapacitated patient, by the surrogate.

B.The Critical Care Scenario: The “Do Everything BUT CPR” Patient

1.Features

1.Death may occur but there is reasonable hope for a recovery.

2.The medical goal of care is prolonging life, restoring function, avoiding or minimizing disability, AND alleviating suffering.

3.Aggressive therapy is employed in the hopes of "turning the patient's condition around." An example would be a patient with generalized sepsis who receives aggressive support for multi-organ failure (e.g., mechanical ventilation, fluid resuscitation, inotropic support, hemodialysis, etc.) and treatment of the septic source (e.g., surgery, drainage, antibiotics, etc.).

4.CPR is withheld because if the patient should progress to a cardiac or respiratory arrest, there are no additional therapies that could be employed making survival from an arrest very unlikely.

2.Concerns

1.The medical goal of care should be reassessed at frequent intervals in light of the patient's condition and response to therapy.

2.The DNR order should not be assumed to affect the aggressiveness or timeliness of medical and nursing care such as diagnostic testing, pulmonary toilet, treatment of fever, pain management, etc.

3.These patients are at risk for “labeling” as a “no code” patient and thus receiving inadequate care by nursing staff in particular around continued aggressive management of physiologic instability and treatment of the underlying cause of disease.

4.The DNR order may or may not be written on the basis of futility. The determination of futility may apply to the patient's overall condition or prognosis, OR to CPR specifically.

C.The Patient Autonomy Scenario: The “Do Only What I Wish” Patient

1.Features

1.Death may or may not be expected this hospitalization or in the near future. The patient may or may not have any condition putting him/her at increased risk of suffering a cardiac or pulmonary arrest.

2.The medical goal of care may be prolonging life, curing disease, restoring function, alleviating suffering, or any combination of those goals.

3.Other therapies may be provided or may be limited also per the patient's wishes.

4.CPR is being withheld because the patient does not wish to receive it regardless of the possibility of its success. Situations might include an older patient who wishes to "let nature take its course" if he should suffer a heart attack or stroke unexpectedly while in the hospital. Or a young nurse who has seen enough "bad" codes that she has decided that under no circumstances--even those that might be reversible--would she wish to received CPR. Or, the cancer patient admitted for a palliative operation where death is not expected this hospitalization but who wishes to insure that he/she is not resuscitated under any situation even if it were unrelated to the diagnosis of cancer and potentially reversible.

2.Concerns

1.Extreme caution needs to be taken not to extrapolate the patient's wish regarding no CPR to other therapies that ARE desired by the patient such as antibiotics, pain management, aggressive diagnostic workups, chemotherapy, etc.

2.Care providers need to guard against misunderstandings about the patient's wishes regarding general aggressiveness of care which could lead to mistreatment and undertreatment.

3.Care providers' need to clarify the CPR order under special circumstances such as surgery.

4.The DNR order may be written on the basis of futility but the determination of futility is specific to the CPR only, not the overall care of the patient.

D.Community-Based or Portable DNR Scenario: The “Help Me But Don’t Save Me” Patient

1.Features

2.The medical goal of care may be prolonging life, curing disease, restoring function, alleviating suffering, or any combination of those. However, often these patients will be those choosing to forego further aggressive medical care such as hospice patients.

3.Other therapies may be provided or may be limited also per the patient's wishes. If EMS personnel are called, they can provide aggressive management of pain or other symptoms but are not obligated to provide CPR in the event of an arrest.

4.CPR is withheld because the patient does not wish to receive it generally in light of their underlying health condition.

5.A community-based No CPR order requires the signature of the patient or the legal surrogate and of the physician.

2.Concerns

1.Extreme caution needs to be taken not to extrapolate the patient's wish regarding no CPR to other therapies that ARE desired by the patient such as assistance with choking, pain management, etc.

2.Care providers need to guard against misunderstandings about the patient's wishes regarding general aggressiveness of care leading to mistreatmentorundertreatment.

3.Care providers' need to clarify the CPR order under special circumstances such as surgery or admission to an acute care facility.

4.The community-based DNR order may be written on the basis of futility.

References

1.Kouwenhoven, W. B., Jude, J. R., & Knickerbocker, G. G. (1960). Closed-chest cardiac massage. JAMA, 173(10), 94-97.

2.Weir, R. F. (1989). Abating treatment with critically ill patients: ethical and legal limits to the medical prolongation of life. New York, NY: Oxford University Press.

3.Bedell, S. E., Delbanco, T. L., Cook, E. F., & Epstein, F. H. (1983). Survival after cardiopulmonary resuscitation in the hospital. N Engl J Med., 309(10), 569-576.

4.Blackhall, L. (1987). Must we always use CPR? N Engl J Med., 317(20), 1281-1285.

5.Lo, B., Saika, G., Strull, W., Thomas, E., & Showstack, J. (1985). 'Do not resuscitate' decisions. A prospective study at three teaching hospitals. Arch Intern Med., 145(6), 1115-1117.

6.SUPPORT Principal Investigators. (1995). The study to understand prognoses and preferences for outcomes and risks of treatments. JAMA, 274(20), 1591-1598.

7.Jecker, N. S. (1994). Calling it quits: stopping futile treatment and caring for patients [editorial; comment]. J Clin Ethics, 5(2), 138-142.

8.Schneiderman, L., Jecker, N., & Jonsen, A. (1990). Medical futility: its meaning and ethical implications. Ann Intern Med, 112(12), 949-954.

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TNEEL-NE2001 D.J. Wilkie & TNEEL InvestigatorsEthics: DNR Decisions