6.

CPR, DNR and

End-of-Life Decisions

 

What is cardiopulmonary resuscitation?

CPR refers to a group of procedures that may include artificial respiration and intubations to support or restore breathing, and chest compression or the use of electric stimulation or medication to support or restore heart function. These procedures can either replace the normal functioning of the heart and lungs or stimulate the person's own heart and lungs to begin working again.

When is CPR used?

CPR is given when a person stops breathing (respiratory arrest) or the heart stops beating (cardiac arrest). During cardiac arrest, all body functions stop, including breathing and the flow of blood to the brain. Sometimes, however, a patient may stop breathing while the heart continues to beat. This "respiratory arrest" may result from choking, or serious lung or neurological disease. If untreated, respiratory arrest will rapidly lead to cardiac arrest.

Why would someone want to refuse CPR?

The burdens of CPR can outweigh the benefits. CPR's success rate depends heavily upon how quickly it is started and the person's underlying medical condition. CPR was never intended for seriously ill or dying people. Originally, it was developed to treat people who have an unexpected arrest due to a heart attack, an adverse reaction to anesthesia, a drug overdose, or an accident like drowning or electrocution.

Although healthy adults who suffer from an unexpected arrest have the greatest chance of being successfully resuscitated, CPR does not always work. In fact, CPR works in only 20 to 50 percent of unexpected arrests. The success rate is much lower for people who are seriously ill or dying. For example, some studies have shown that individuals with overwhelming infection have less than a 3 percent chance and those with metastasis cancer have virtually no chance of surviving to discharge from the hospital following CPR.

When a person is seriously ill or dying, cardiac arrest marks the terminal moment of a disease when the body is shutting down. For a dying person, cardiac arrest can bring a natural end to the exhaustion of battling a disease. If CPR is initiated, it disrupts the body's natural process of shutting down, prolonging the dying process. Although CPR may restart the heart, its success may be temporary or it may leave the person further compromised, brain damaged or dependent upon a ventilator. CPR often is aggressive and invasive, a procedure that many dying persons and their families wish to avoid.

What is a do-not-resuscitate order?

A DNR order is a physician's written order instructing health care providers not to attempt CPR in case of cardiac or respiratory arrest. A person with a valid DNR order will not be given CPR under these circumstances. Unlike a living will or a medical power of attorney, a DNR order cannot be prepared by the individual. Although it is written at the request of a person or his or her family, it must be signed by a physician to be valid.

Why is DNR order needed to refuse CPR?

CPR is an emergency procedure that is potentially life-saving if initiated immediately. Without a physician's order not to resuscitate, the health care team must initiate CPR because in an emergency there is no time to call the attending physician, determine the person's wishes or consult the family. If a person wishes to refuse CPR, that wish must be communicated to the health care team by a DNR order signed by the attending physician.

Will instructions in a living will enable a person to avoid CPR?

Not by themselves. In an emergency there is no time to consult a living will. Unless the health care team has received clear instructions from the attending physician not to resuscitate a person, they must initiate CPR.

Instructions about CPR that are documented in a living will indicate a person's wish not to receive CPR in certain circumstances. This wish must be translated into a physician's DNR order; without a DNR order, the instructions will not be honored.

Does a DNR order mean a person won't receive any treatment?

No. "Do not resuscitate" does not mean "do not treat." A DNR order covers only one type of medical treatment—CPR. Other types of treatment including intravenous fluids, artificial nutrition and hydration, and antibiotics must be discussed with the physician separately. In addition, although CPR will not be given to a person who has a DNR order, all other measures can and should be used to keep a person comfortable.

Are DNR orders governed by state law?

Only a handful of states have laws governing DNR orders for health care facilities. More often, DNR orders are regulated by a facility's policy. All health care facilities, including nursing homes and rehabilitation centers, are required to have a DNR policy in place if they wish to be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), a private not-for-profit, voluntary accrediting agency. Most health care facilities seek accreditation by JCAHO.

JCAHO requires that a DNR policy describe the following: the procedure for reaching a decision about a DNR order, the mechanisms in place for resolving conflicts in decision-making and the role of physicians, nursing personnel, other staff and family members in reaching a decision about a DNR order. The policy also must include provisions that ensure that the rights of patients are respected. The policy should be in writing and made available to patients and their families if requested.

Who can consent to a DNR order?

An individual or his or her health care agent or family member can authorize a DNR order. Although policies may differ, in general a DNR order must first be discussed with the person, if he or she has the capacity to make medical decisions. If a person is incapacitated, a physician can then consult instructions left in a living will or speak with an appointed health care agent. Decisions about cardiopulmonary resuscitation generally can be made by a family member or a close friend if a person is incapacitated and has not left a written advance directive.

Sometimes, physicians are reluctant to start discussions about DNR orders. Individuals and their families should take the initiative to approach the physician about a DNR order, if they think it might be appropriate, and not wait for the physician to raise the issue.

When should a DNR order be discussed with a physician?

If a person is seriously ill or dying and death is expected, the physician should be approached about a DNR order as soon as possible. Ideally, a decision about a DNR order should be made while a person is alert and able to think clearly, and not at the last moment when he or she may be weak and disoriented from the illness. However, if a person does not have the capacity to make a decision about a DNR order, it is important that the family approach the physician with their concerns. A discussion initiated sooner rather than later gives individuals and their families time to reflect on the decision and, in the end, offers the best protection against unwanted treatment.

What questions should be asked when discussing a DNR order with a physician?

Before making a decision about CPR, individuals and their loved ones need to understand both the burdens and benefits of CPR, which can vary depending on individual's underlying condition. The physician should be prepared to discuss the procedure in detail as well as address the probabilities for successful resuscitation based upon the medical condition. The physician should be asked how he or she defines a "successful" resuscitation. Does "successful" mean the patient will be able to leave the hospital, and if so, in what kind of condition? If it is unlikely that the person will be able to leave the hospital, what exactly will the resuscitation attempts accomplish? If the physician does not think resuscitation would be successful, he or she should be willing to discuss the reasons why.

What if an individual or his or her family disagree with the physician's recommendation?

First, the individual and his or her family should approach the physician to clear up any misunderstandings about the person's wishes, prognosis, and treatment options. They can also request that a meeting be arranged with the physician, nurse and other members of the health care team to discuss possible reasons why an agreement cannot be reached. Often, conflicts arise because of a lack of communication. However, if the parties involved are unable to resolve their differences, it is important that the family learn what resources the facility makes available for mediating and resolving conflict.

Health care facilities are required to have a mechanism in place for resolving conflicts that arise over decisions about CPR. A social worker or patient representative may be a good source of information about how to proceed. The family should also ask to see a copy of the facility's policy on DNR orders. The policy should describe the facility's mechanism for resolving conflict. For example, many facilities give patients and their families the opportunity to bring disputes before an ethics committee that can provide a neutral environment in which to mediate and resolve conflict.

Can a physician write a DNR order without consulting the individual?

Yes, in limited circumstances. If a physician feels that discussion of a DNR order would be harmful, a physician is not obligated to consult the individual directly before writing the order. In special circumstances, if an individual is incapacitated and an authorized surrogate is not available, a physician may, depending upon the facility's policy, write a DNR order if he or she believes that CPR would not be successful given the person's underlying illness. In general, however, physicians are obligated to discuss a DNR order with an individual or his or her authorized surrogate, and must obtain consent before treatment can be withheld or withdrawn. Informed consent is a basic right of patients that must be respected by a facility's policy on DNR orders.

Will a DNR order remain effective when an individual is transferred between health care facilities, for example from a nursing home to a hospital?

Theoretically, yes. A person's DNR order should accompany him or her on every transfer. Once the person arrives at the new facility, a new DNR order may need to be written based on that facility's policy. It is important that family and friends monitor the transfer to ensure that the DNR order accompanies the person and is properly documented in the medical record at the new facility. A DNR order or other important documents like a living will and medical power of attorney can be misplaced or overlooked during a transfer.

Will a DNR order be honored during surgery?

Usually not. DNR orders often are suspended during surgery. Cardiac or respiratory arrest during surgery may be due to the circumstances of surgery and not the underlying illness, and the chances of a successful resuscitation thus may be better. DNR orders should be reinstated after a specified period of time following the surgery. It is important that a person and his or her family talk to the surgeon in advance to make sure all parties understand what should happen in the event of an arrest during or shortly after surgery. The surgeon should also discuss how soon after surgery a DNR order will be rewritten.

Can a DNR order be revoked?

Yes. An individual or authorized surrogate can at any time cancel a DNR order by notifying the attending physician, who must then remove the order from the medical record.

Nonhospital Do-Not-Resuscitate Orders

What is a nonhospital DNR order?

Unlike regular facility DNR orders, nonhospital DNR orders are written for people who want to refuse CPR and are outside a health care facility, either at home or in a residential care setting. Also referred to as a prehospital DNR order, a nonhospital DNR order directs emergency medical care providers, including emergency medical technicians, paramedics and emergency department physicians, to withhold CPR. These orders need to be signed by a physician and generally are written on an official form, but depending upon the state, they also may be issued on a bracelet, necklace or wallet card. Although honored by emergency medical providers, nonhospital DNR orders are not binding upon bystanders who may initiate resuscitative measures in an emergency.

Why are nonhospital DNR orders needed?

Emergency situations demand an immediate response. Emergency medical service (EMS) personnel are trained to act quickly and to save lives. Once called to a scene, they must do all they can to stabilize and transport a person to the nearest hospital, including administering CPR if necessary. If a person wishes to refuse CPR in the home, he or she must have a nonhospital DNR order. Without a nonhospital DNR order, EMS will initiate CPR if a person is in cardiac or respiratory arrest. It is important to remember, however, that as long as a person has decision-making capacity, he or she can refuse any form of medical treatment, including emergency care.

Will all treatment be withheld from someone who has a nonhospital DNR order?

No. A nonhospital DNR order means "no CPR;" it does not mean "no treatment." If a person has a valid nonhospital DNR order, CPR is the only medical treatment that will be withheld. If a person with a nonhospital DNR order is suffering from any injury or problem other than cardiac or respiratory arrest, EMS personnel will do whatever is necessary to stabilize and transfer the person to the nearest hospital.

Will a living will or medical power of attorney be honored by EMS personnel if a person suffers a cardiac or respiratory arrest?

No. Generally, advance directives such as living wills and medical powers of attorney are not effective in a medical emergency and are not binding upon EMS personnel. There is no time in an emergency either to consult the directions in an advance directive or determine a person's underlying medical condition. Furthermore, EMS personnel are not authorized to evaluate an advance directive or make medical diagnoses.

Once the person comes under the care of a physician qualified to evaluate the contents of a living will and instructions of a health care agent in light of that person's overall prognosis, any unwanted treatment that has been started by EMS personnel can be stopped.

Are nonhospital DNR orders governed by state law?

Yes. Many states have laws in place governing nonhospital DNR orders. With the growth of hospice care and the increasing desire of dying patients to spend their last days at home has come the need to protect people against unwanted emergency care. Nonhospital DNR laws meet this need by allowing qualified persons to refuse emergency resuscitative measures. If you are interested in learning whether your state has a nonhospital DNR law, call Choice In Dying at 212-366-5540.

What should I do if my state does not have a nonhospital DNR law?

First, you should check with the State Department of Health and county EMS agency to determine if a statewide policy or any local protocols governing nonhospital DNR orders exist. If no statewide policy or local protocols exist, you can try to make private arrangements with your physician and local EMS agency. A physician can usually write a DNR order on official stationery explaining its applicability to the nonhospital setting. In a small community, a physician also may be able to notify the local EMS agency about the situation and the DNR order, explaining the patient's wishes not to receive CPR. However, without a state law or policy governing its use, it is unclear whether such an order would be legally binding on EMS personnel.

If a family wants to be certain that a loved one who is seriously ill would not be resuscitated against his or her wishes, they should resist calling 911. To avoid allegations of abuse or neglect, the family should make prior arrangements with a doctor who can oversee their loved one's care and be available to sign a death certificate when the time comes, certifying that the death was expected and due to natural causes.

Who should consider a nonhospital DNR order and when?

Nonhospital DNR orders generally are intended for the terminally ill who have chosen to die at home, or for people with a serious chronic illness for whom the success rate of resuscitation is very low. Depending upon the state law or policy, there may be restrictions on who can qualify for a nonhospital DNR order. Remember, these orders must be signed by a physician to be valid.

A nonhospital DNR order should always be considered part of a discharge plan when a seriously or terminally ill patient leaves the hospital, particularly if the person had a DNR order during the hospital stay. These orders should also be considered for individuals who have chosen to die at home or who are enrolled in a hospice program. People who have questions and concerns about whether they qualify for a nonhospital DNR should consult a physician.

Where can I get a nonhospital DNR form?

From your physician or local hospital. If your physician or local hospital do not have the forms available, you should ask them to contact the State Department of Health or State EMS Agency to obtain them. Some local organizations may make the forms available.

Where should a nonhospital DNR order be kept?

Keep a nonhospital DNR order in a visible location, close to the person, such as above the bed or on the refrigerator door. Caregivers should also have a copy of the order ready to present to EMS if necessary. EMS personnel cannot honor a nonhospital DNR order unless presented with the valid form. They cannot take oral directions from family members or home health aides. In some states, EMS personnel will honor nonhospital DNR bracelets, necklaces or wallet cards, even without a nonhospital DNR form.

Is it ever appropriate to call EMS if someone has a nonhospital DNR order?

Usually, no. EMS should be called only if caregivers are unsure whether a person is experiencing cardiac or respiratory arrest and help is needed short of CPR. To avoid unwanted treatment and hospitalization, family members and close friends should plan ahead for their loved one's care. Good planning might involve enrolling their loved one in a hospice or visiting nurse or home care program. Doctors and nurses can provide valuable information and advice about how to care for a loved one who is dying and what to expect when death is imminent; sometimes they may be available to visit the home. If the family knows what to expect, they will not feel the need to call EMS;

Instead they should make arrangements to call the eventually a funeral director.

A paramedic talks about nonhospital DNR orders

Another tragic predicament we encounter all too frequently occurs when family members call 911 but then do not want us to take their loved one to the hospital. Too many times I've been called to the homes of terminally ill patients because the family wanted us to give the patient oxygen for a few minutes or assist the family to suction a tube. Once an ambulance is called, we are mandated to bring the patient to the hospital for examination by a physician. This is true even if a valid DNR order exists because the order is valid only to prevent CPR. Unless the patient is completely alert and oriented, capable of making a rational decision and refusing to go - we are obligated legally to take him or her to the hospital.

Families need to know that when the time of death arrives they can make arrangements with the funeral home and the doctor. They do not need to call 911.

EMS workers are not trying to avoid work; we wish to avoid the wrong type of work. As someone on the front lines in this battle, I can promise you : It is wrong to do CPR, place IV's and endotracheal tubes, and defibrillate people who wish to die with dignity and in peace. It's not what the patient wants. It's not what you want. And it surely is not what we want to do.

Mr. Paul Shapiro works as a paramedic in New York City. His book, Paramedic, was published by Bantam.

Courtesy of Choices, the newsletter of Choice in Dying.

What happens to a nonhospital DNR order when someone is taken to a hospital?

If a person is admitted to the hospital for any reason, it is important that the nonhospital DNR order goes with the person. If EMS personnel are involved, they should take the order with them in the ambulance, but it is still advisable for family members to bring a copy of the order with them. Although a new DNR order should be written at the hospital by the admitting physician, it is important that family members check to make sure that a facility DNR order is in place. Hospital personnel are sometimes unfamiliar with DNR laws or policies, and in an emergency, important papers can be overlooked.

Can a nonhospital DNR order be revoked?

Yes. The patient, or the patient's authorized surrogate can cancel a nonhospital DNR order at anytime by notifying the physician who signed the order and by destroying the form and/or bracelet.

By permission of Choice In Dying, Inc. (1996).

Discussion of Legal and Ethical Issues

A do-not-resuscitate (DNR) order instructs medical staff not to revive a patient if breathing or heart functioning has ceased. If a DNR order is attached to patient's medical chart, emergency procedures such as mouth-to-mouth resuscitation, external chest compression, electric shock and insertion of tubes to open air passages will not be initiated. DNR practices, however, vary from jurisdiction to jurisdiction and even among hospitals within the same jurisdiction.

A patient's right to refuse medical treatment such as cardiopulmonary resuscitation (CPR) is widely acknowledged. Such a preference may be expressed in advance by a patient in writing. A written directive by a patient to withhold CPR may serve as the basis for a DNR order (also known as a "no-code" order).

If the patient has executed a durable power of attorney expressly to make health-care decisions in his or her behalf, the attorney-in-fact or the agent will make the decision concerning DNR orders, basing his decision on preferences previously expressed by the patient. In most cases, however, no advance decision concerning CPR or the appointment of a surrogate decision maker has been made and a decision concerning CPR must be made in an emergency situation. A considerable amount of uncertainty exists in both the medical and legal professions as to whether the implementation of DNR orders without the consent of the patient is legal. In response to such uncertainty, in the past few years, several states have enacted legislation addressing this issue. Patients in states which have not enacted legislation depend for the most part on the policies of individual hospitals.

Hospital policies generally require that CPR be attempted on an incapacitated patient unless a DNR order has been written by the patient's attending physician and the patient's family agrees to such order. It is thus possible for a patient's family to refuse to consent to the withholding of CPR and block a DNR order even though resuscitation may be futile. There is, however, no obligation on the part of hospitals to provide futile medical treatment.

Guidelines for the Appropriate Use of Do-Not-Resuscitate Orders

1. Efforts should be made to resuscitate patients who suffer cardiac or respiratory arrest except when circumstances indicate that administration of CPR would be futile or not in accord with the desires or best interests of the patient.

2. Physicians should discuss with appropriate patients the possibility of cardiopulmonary arrest . . . [preferably] in an outpatient setting when general treatment preferences are discussed.

3. If a patient is incapable of rendering a decision regarding the use of CPR, a decision may be made by a surrogate decision maker, based on the previously expressed preferences of the patient or, if such preferences are unknown, in accordance with the patient's best interests.

4. The physician has an ethical obligation to honor the resuscitation preferences expressed by the patient or the patient's surrogate . . . .However, if, in the judgment of the treating physician, CPR would be futile, the treating physician may enter a DNR order into the patient's record. When there is adequate time to do so, the physician must first inform the patient, or the incompetent patient's surrogate, of the content of the DNR order, as well as the basis for its implementation. . . .

5. Resuscitative efforts should be considered futile if they cannot be expected either to restore cardiac or respiratory function to the patient or to achieve the expressed goals of the informed patient.

6. DNR orders, as well as the basis for their implementation, should be entered by the attending physician in the patient's medical record.

7. DNR orders only preclude resuscitation efforts in the event of cardiopulmonary arrest and should not influence other therapeutic interventions that may be appropriate for the patient.

Source: Council on Ethical and Judicial Affairs, American Medical: Guidelines for the Appropriate Use of Do-Not-Resuscitate Orders, 265:14 JAMA 1868, 1871 (1991).

At present New York is the only state that has codified the do-not-resuscitate procedure. The protocol to be used in DNRs can be summarized as follows:

(1) Every patient who has not consented to the issuance of a DNR order is presumed to consent to CPR.

(2) If the patient has decision-making capacity, the attending physician must obtain the patient's consent in the presence of two witnesses before issuing a DNR order.

(3) If the patient lacks decision-making capacity, the attending physician and a concurring physician must certify in writing their opinions of the cause and probable duration of the patient's incapacity. Notice of this determination must be given to the patient and the surrogate decision maker (the legal guardian or next of kin). The surrogate may consent to a DNR order only after written determination by the two physicians that the patient has a terminal condition, the patient is irretrievably comatose, resuscitation would be medically futile, or resuscitation would impose an extraordinary outcome. For purposes of this determination, a terminal condition is defined as a condition that is expected to result in death within one year.

(4) If the attending physician and a concurring physician agree that discussing a DNR order with a patient who has decision-making capacity would cause the patient immediate harm, a "therapeutic exception" allows an order to be issued with the consent of the next of kin only.

(5) In the case of acute care hospitalization, the DNR order must be reviewed every three days.