Do Not Resuscitate
Do Not Resuscitate (DNR) orders are medical directives to withhold efforts to revive a patient who has a cardiac or respiratory arrest. DNR orders came into use in the 1970s as a response to the widespread practice of cardiopulmonary resuscitation (CPR). CPR is an emergency intervention that uses a variety of techniques to restore the heartbeat and breathing. CPR includes such basic life support as external chest compression and mouth-to-mouth ventilation, as well as advanced cardiac life support such as electrical defibrillation and cardiac medications. A DNR order tells medical professionals not to perform CPR if the patient's heartbeat or breathing stops.
When it was first introduced in the early 1960s, CPR was a heroic, life-sustaining act. It was a technique used on only a select group of acutely ill but otherwise relatively healthy patients. By the end of the following decade, however, CPR had become a routine intervention for all patients facing imminent death. With this widespread use of CPR came a growing recognition that it was neither effective nor desirable for some patients. For example, patients with aggressive cancer or serious infection had almost no chance of recovery after CPR. Other patients who did survive after CPR often ended up with brain damage or permanent disabilities. At the same time that poor outcomes from CPR were being recognized, patients were demanding to be more involved in medical decisions. The result was the institution of DNR orders.
Participation in the DNR Decision
An ongoing debate about DNR has involved the extent to which patients or their surrogate decision makers must agree to such orders. Through the late 1970s and early 1980s, some hospitals routinely created DNR orders without any discussion with the patient or the patient's family, and they did not clearly document the DNR order in the patient's chart. But these practices were abandoned as the bioethics movement and the courts emphasized the right of patients or their surrogate decision makers to refuse medical treatment, including life-sustaining therapies such as CPR. Most health care providers and well-recognized health professional groups and accrediting bodies began to support DNR policies that require the patient to be informed of the risks and benefits of CPR and to give consent that CPR not be used. Some well-respected physician ethicists and medical groups, however, advocate that physicians should have the ability to write DNR orders without a patient's consent in situations in which it has been determined that CPR would have no medical benefit.
Communication and Knowledge about CPR and DNR Orders
Despite policies that require consent to a DNR order, informed discussions between patients and physicians about CPR and other life-sustaining treatments occur infrequently. Only about one patient in seven reports having discussed personal preferences for life-sustaining treatment with a physician. Even when patients have life-threatening illnesses such as AIDS, cancer, and congestive heart failure, such discussions occurred less than 40 percent of the time in some studies. In many cases, the decision about a DNR order is broached only after extensive procedures have been attempted and at a time when patients are no longer capable of making an informed decision.
This lack of communication contributes to three concerns. First, many people have unrealistic expectations about the likely success of CPR. When CPR was first described in 1960, it referred to heart massage by the exertion of pressure on the chest. The success rate of 70 percent survival to hospital discharge was quite high, largely because it was applied to a small group of patients who experienced a cardiac arrest in the operating room or postoperative recovery rooms. By the early twenty-first century, CPR included not only heart compression and mouth-to-mouth resuscitation but also a host of advanced supports such as electrical defibrillation paddles, powerful drugs, and an assortment of mechanical breathing devices. This range of interventions is generally referred to as a "code" in which a special team responds to resuscitate a patient. But success rates are nowhere near those reported in original studies.
Research in the 1980s and 1990s showed that for all patients undergoing CPR in the hospital, just under one-half survived the code itself and one-third survived for twenty-four hours. Approximately 15 percent of patients undergoing CPR in the hospital survived to discharge. About 30 percent of those who survived suffered a significant increase in dependence and required extensive home care or institutionalization. Survival to discharge from the hospital was much poorer when certain diseases or conditions were present. In some studies, for example, no patients with metastatic cancer and only 3 percent of patients with sepsis (a widespread infection) survived to discharge. Outcomes in some studies of frail, elderly patients in long-term care facilities showed survival rates of 5 percent or less, prompting some health care providers to suggest that CPR should not even be offered to residents of nursing homes and other long-term care facilities.
The general public, however, often has an overly positive impression about the success rates of CPR. As portrayed on popular television medical shows, CPR is much more effective than in real life. According to one study, two-thirds of CPR patients survive on television, a much higher percentage than any published medical study. The same study reported that on television only 17 percent of patients getting CPR were elderly. In reality cardiac arrest is much more common in older people than in any other age group. Furthermore, three-quarters of cases of cardiac arrest on television resulted from accidents, stabbings, lightning strikes, and other injuries, whereas in the real world 75 percent or more of cardiac arrests were triggered by underlying heart disease.
Knowledge about the outcomes of CPR is especially important because it has been shown to affect preferences for care. Surveys have shown that as many as 90 percent of elderly outpatients and a range of 44 to 88 percent of hospitalized elderly desire to have CPR in the event of a cardiac arrest. Even when elderly patients were asked whether they wanted CPR if they had a serious disability, 20 to 45 percent said they would. Clinicians at one geriatric practice asked patients about their preferences for CPR if they were acutely ill and if they were chronically ill. These patients were then educated about the probability of surviving to discharge under these conditions. Once they were given prognostic information, preferences for CPR dropped nearly 50 percent.
A second area of concern is that the lack of communication about CPR results in common misunderstandings about DNR orders. Many patients believe incorrectly that having a living will or other type of written advance directive automatically means that a patient will have a DNR order written. Instead, while an advance directive may express a patient's desire to have a DNR order written under certain circumstances, DNR orders—like all medical orders—must be authorized by a physician who is treating the patient. Also, some patients assume that a DNR order directs that all medical treatments be stopped and only comfort care provided. In some circumstances, however, other aggressive therapies—including staying in an intensive care unit—are continued for patients with DNR orders.
Moreover, there are circumstances in which restricted or limited DNR orders are appropriate. For example, if it is determined that further attempts at CPR would not benefit a patient who is on a ventilator or a breathing machine, then an order might be written not to give cardioactive medications should a cardiac or pulmonary arrest occur. On the other hand, it might also be determined that a patient would want cardioactive medications and chest compressions but would not want to be intubated and put on a breathing machine. Because there are multiple options, it is essential that physicians thoroughly discuss DNR options with patients or their surrogate decision makers and that decisions are carefully documented in the patient's medical record.
Third, the lack of genuine communication means that physicians are often unfamiliar with patients' preferences about CPR and must rely on family members to help decide whether a DNR order is appropriate. Family members, however, also are very poor predictors of what patients would actually want, answering wrongly up to 40 or 50 percent of the time in some scenarios. Uncertainty about patient wishes concerning CPR also means that decisions about DNR orders are often delayed until the patient is near death.
A major, multihospital, longitudinal study of these issues focusing on more than 9,000 patients— the Study to Understand Prognosis and Preferences for Outcomes and Treatment (SUPPORT) —discovered that 79 percent of the patients who died in the hospital had a DNR order but that almost half of these orders had been written in the last two days before death. Almost 40 percent of these patients had spent at least ten days in the intensive care unit, and, of those able to communicate, more than half were in moderate or severe pain at least half of the time in their final days. About one-third of the patients expressed a desire not to be resuscitated, but less than half of their physicians understood this desire.
An issue of special concern involves the patient with a DNR order who needs to have surgery or some other medical intervention that requires the use of anesthesia or other agents that affect resuscitation. At some hospitals, it is institutional policy to automatically suspend a DNR order while a patient is undergoing procedures that may require resuscitative measures. The rationale for such policies is that if the procedure requires a patient to be artificially resuscitated through the use of a ventilator or chemical agents, then a DNR order would be illogical. Some hospitals, however, forbid the practice of automatically suspending a DNR order during surgery. Rather, they require the need for resuscitative measures during surgery or other procedures be discussed with the patient and that agreed-upon circumstances for using or not using resuscitative measures be put in writing.
Some states have authorized the use of "durable" DNR orders. Such orders can travel with the patient and can be recognized by a wide range of health care personnel at different facilities and at the patient's home. Durable DNR orders eliminate the problem of patients needing to have a DNR order written each time they enter a health care facility and mean that patients at home can have their DNR wishes honored by emergency services personnel. Without a durable DNR order, emergency services personnel are required to resuscitate a patient at home, even if the patient had a DNR order recently written in the hospital.
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CHARLES A. HITE GREGORY L. WEISS