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Reviving the Conversation Around CPR/DNR
Jeffrey P. Bishop , Kyle B. Brothers , Joshua E. Perry & Ayesha Ahmad
To cite this article: Jeffrey P. Bishop , Kyle B. Brothers , Joshua E. Perry & Ayesha Ahmad (2010)
Reviving the Conversation Around CPR/DNR, The American Journal of Bioethics, 10:1, 61-67
To link to this article: http://dx.doi.org/10.1080/15265160903469328
Published online: 12 Jan 2010.
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The American Journal of Bioethics, 10(1): 61–67, 2010
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DOI: 10.1080/15265160903469328
Target Article
Reviving the Conversation Around
CPR/DNR
Jeffrey P. Bishop, Vanderbilt University Medical Center
Kyle B. Brothers, Vanderbilt University Medical Center
Joshua E. Perry, Vanderbilt University Medical Center
Ayesha Ahmad, Universities of Exeter and Plymouth
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This paper examines the historical rise of both cardiopulmonary resuscitation (CPR) and the do-not-resuscitate (DNR) order and the wisdom of their continuing status
in U.S. hospital practice and policy. The practice of universal presumed consent to CPR and the resulting DNR policy are the products of a particular time and were
responses to particular problems. In order to keep the excesses of technology in check, the DNR policies emerged as a response to the in-hospital universal presumed
consent to CPR. We live with this historical concretion, which seems to perpetuate a false culture that the patient’s wishes must be followed. The authors are critical of
the current U.S. climate, where CPR and DNR are viewed as two among a panoply of patient choices, and point to UK practice as an alternative. They conclude that
physicians in the United States should radically rethink approaches to CPR and DNR.
Keywords: cardiopulmonary resuscitation, do-not-resuscitate orders, futility, presumed consent
In the United States, the do-not-resuscitate (DNR) order is
ensconced in hospital policy and in the psyches of American
doctors. Its existence, however, is dependent upon a practice
that preceded it, namely, the use of CPR for all patients who
sustain cardiopulmonary arrest. Yet the diseases and mechanisms that result in cardiac or pulmonary arrests are different from one another, with different causes and prognoses.
Yet they share a final common pathway—cardiopulmonary
arrest. Thus, blanket presumption for cardiopulmonary resuscitation (CPR) and policies regarding do-not-resuscitate
(DNR) orders assume the same sort of thing is being treated,
even while CPR and advanced cardiac life support (ACLS)
protocols do not.
Adding our voices to a growing chorus (Helft et al. 2000;
Hofmann and Schneiderman 2007; Jecker 2007; Tomlinson
and Brody 1990), we suggest that these widespread U.S.
practices (not the ACLS protocols) have outlived their utility precisely because they obscure what is known by all:
Resuscitation, although able to stay death in a limited number of cases, is often a pseudo-option that will not result
in a satisfactory restoration to health. In what follows, we
first document the history of presumed consent in CPR and
the rise in DNR orders and consider the unintended consequences that have resulted in the current environment, including the trend toward medical personnel feeling coerced
into applying medical interventions that may not be medically indicated. We then move to a brief consideration of the
differing approach suggested by UK practice and the theoretical challenges presented by the long-standing futility
debate. We conclude by sketching a set of educational and
practice initiatives that hospitals and medical schools in the
United States should undertake in the near future as first
steps in reforming the cultural practices of presumed consent to CPR and the application of DNR orders as a tool of
patient preference.
A SHORT HISTORY OF CPR, DNR
In the 1950s and 1960s, a series of articles by Kouwenhoven, Jude, and Knickerbocker forged the scientific basis
for our current practices of CPR (Jude et al. 1961a; 1961b;
Kouwenhoven et al. 1960; Kouwenhoven and Kay 1951).
Initially, CPR found greatest reception intra- and postoperatively, when cardiovascular and circulatory problems are
unmasked by the stressors of surgery, blood loss, anesthetics, and other medications. When previously physicians
were only able to allow patients to die, now they could
resuscitate them with relatively simple protocols and procedures. Soon, CPR became a technique utilized throughout
the hospital and beyond (Wilder et al. 1964; Zoch et al. 2000).
Regardless of medical training, all citizens were encouraged
to become certified in basic life support (BLS), while all
health care personnel were urged to become certified in advanced cardiac life support (ACLS) (Annas 1982a). Today,
automatic defibrillators can be routinely found throughout American public places, such as airports and municipal buildings. Presumed consent to CPR has ensconced
medical optimism into public policy and become the social
norm.
Address correspondence to Jeffrey P. Bishop, Vanderbilt University Medical Center, Center for Biomedical Ethics and Society, 2525 West
End Ave, Suite 400, Nashville, TN 37203, USA. E-mail: [email protected]
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By the early 1970s it became clear that the ubiquitous
use of CPR/ACLS was no technological miracle for many
patients. Patients in the final stages of their lives would finally reach the point of cardiac arrest—the final common
pathway for all deaths—and then the “crash” or “code”
team would arrive to perform CPR/ACLS, “a desperate,
invasive medical intervention which for many patients has
a remote chance of success” (Boozang 1993). By 1976, as
patients and doctors became aware of CPR’s limited usefulness, papers began to appear arguing that orders not to
resuscitate should be an option (Rabkin et al. 1976).
By the mid-1970s, medical ethicists increasingly challenged medicine’s creeping technological optimism. At the
same time, the patient rights movement displaced doctor
paternalism in favor of patient self-determination (Jonsen
1998). By the 1980s, at least in the United States, the donot-resuscitate order was beginning to be perceived as part
of the patient’s right to claim back self-determination in
the face of paternalistic doctors on an implicit quest for
technologically mediated immortality. CPR, along with its
rejection—DNR orders—began to be perceived by both patients and relatives, and even by many doctors, not as a
medical intervention with medical indications to be determined by one with medical training, but rather as another
option among the choice continuum offered to patients and
patient surrogates (Blackhall 1987; Carson and Siegler 1982).
So deeply is DNR embedded in the patient choice
paradigm that it could be called a “patient order” not to
attempt resuscitation that is given to the medical team. And
in most U.S. health care environments, if the patient does
not wish to give the “order” not to resuscitate, then the
medical culture interprets the patient’s wishes as an implicit “order” by the patient to the health care personnel to
utilize CPR/ACLS. Some jurisdictions, such as New York,
have actually enshrined into law a presumption in favor of
resuscitation absent an order not to resuscitate (N.Y. Public
Health Law 2009). In most institutions, hospital policy reflects this presumption that CPR/ACLS will be performed
unless a DNR order is requested by the patient, because of
the “emergency” status often conferred upon the CPR procedure (Smith 2000). Moreover, even in those jurisdictions
and institutions without specific statutes, case law, or official
policy on point, ward culture seems to suggest that in the
absence of a patient’s or surrogate’s DNR order, CPR/ACLS
must be done even if the treatment team does not think it
is medically warranted (Muller 1992). Whether it be fear of
litigation, inappropriate or unclear guidelines, or the “do
everything” directive of the patient or his family, “physicians and other health care workers often administer CPR
in situations where its use is contraindicated” (Smith 2000).
Even while there is a false belief that doctors must perform CPR/ACLS on all patients who have refused the DNR
option, the early ethics literature supported physician decision making about CPR premised upon professional medical judgment. For instance, George Annas’s piece, “CPR:
When the Beat Should Stop,” makes a distinction that is reflected in most jurisdictions (1982b). His distinction is this:
Poor prognosis falls within the realm of medical decision
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making; poor quality of life is the realm of patient decision
making. Of course, the distinction he makes is somewhat
simplistic. Doctors prognosticate not only about quantity
of life, but also about quality of life, and falling back on
quantity of life as the purview of the doctor is as much a
value judgment as evaluating quality of life. In the mid1990s, Layson and McConnell claimed that consent to DNR
orders is not always necessary, yet a widely held belief persists, at least in the United States, that it is always a patient’s
decision (1996).
DIFFERING POLITICAL SPACES—NEW YORK AND THE
UNITED KINGDOM
U.S. courts have not been consistent when addressing areas of patient–physician disagreement. Moreover, individual state statutes regulating DNR orders vary throughout
the United States, and analysis of their provisions is often
vexed. While most laws in the United States support physician decision making, the culture seems to bow to patient
choice (Moore 2007; Pope 2007; Sabatino 1999). Case law
precedent and state statutes exist supporting the concept of
physician decision making (M.D. Code Ann., Health-Gen.
Law 1993; Bryan v. Rectors 1996; V.A. Code Ann. 2000; Tex.
Health & Safety Code Ann. 2003). New York state law, however, is illustrative of the default practice, driven by a culture
that bows to patient choice.
Dating back to 1988, New York’s DNR law was enacted
“to clarify and establish the rights and obligations of patients, their families, and health care providers regarding
cardiopulmonary resuscitation and the issuance of orders
not to resuscitate” (N.Y. Public Health Law 1988). As noted
by Professor George P. Smith, “legislating the authority to
issue DNR orders to clinicians” was intended by the New
York state legislature to “increase the level of care to seriously ill patients and the level of doctor-patient communication” (Smith 2000). The “central flaw” in New York’s
law, however, was its “presumption that all residents of
New York have, in medical emergencies, consented to CPR”
(Smith 2000). Over time a widely disseminated 1992 pamphlet issued jointly by the New York State Task Force on Life
and the Law, the New York State Department of Health, the
Medical Society of the State of New York, and the Hospital
Association of New York State created a standard of practice in which an attending physician—with a confirming
second opinion that CPR would be “medically futile”—was
justified in the eyes of the medical community for entering
a DNR order over the objection of a patient’s health care
surrogate (McArdle 2002).
In April 2003, however, then-New York Attorney General Eliot Spitzer opined that despite approval within the
medical community, such unilateral physician action was
not sanctioned by the law. Instead, the Attorney General
asserted that New York’s DNR law requires a physician
to obtain consent of the patient’s health care surrogate before entering a DNR order, even when the physician concludes that administration of CPR would be “medically futile” (Spitzer 2003). Attorney General Spitzer was explicit
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Reviving the Conversation Around CPR/DNR
in his legal opinion that if a disagreement arises between a
physician and a patient’s health care surrogate, the physician must proceed to mediation and, if necessary, litigation. New York practice, informed by “over-interpretations”
and clinical misperceptions of the statute’s requirements
and bolstered by Spitzer’s opinion, exemplifies how many
health care providers on the wards around the United
States (mis)understand DNR orders (Baker 1995; Kamer and
McClung 1995).
The practices around do not attempt resuscitation
(DNAR) orders in the United Kingdom provide an interesting contrast to those in the United States generally, and
New York particularly. In the United Kingdom, the DNAR
order is a medical order given by the doctor not to attempt
resuscitation. The General Medical Council (GMC), which
licenses and regulates all doctors in the United Kingdom—
much like the various state boards of medical examiners in
the United States—acts in a quasi-legislative way. Among
other functions, the GMC publishes advice and guidance on
dealing with DNAR orders. The GMC’s Guidance on Withholding and Withdrawing Treatments states: “A patient’s own
views, about whether the level of burden or risk outweighs
the likely benefits from successful CPR, would be central in
deciding whether CPR should be attempted” (GMC 2002).
Additionally the guidance notes that “failing to give patients or, where appropriate, those close to the patient, the
opportunity to be involved in reaching a decision can cause
more distress at a later stage, when the patient or a relative
discovers a DNAR order was made, than if the issue were
tackled sensitively at the outset” (GMC 2002).
Paragraph 89 states that when patients refuse CPR, their
decision must be respected. The next paragraph states: “You
should usually comply with patient’s requests to provide
CPR, although there is no obligation to provide treatment
that you consider futile” (GMC 2002).
In the United Kingdom, if the doctor thinks CPR has a
reasonable chance of success, and if the patient decides to
forgo CPR/ACLS, then the doctor enters the DNAR order.
The GMC guidelines for DNAR orders are mostly geared toward encouraging doctors to inform the patient and/or relatives of the physician’s decision to place a DNAR order into
the chart. These guidelines exist to help smooth the communication between doctor and patient. The presumption
is that the doctor is making a medical decision, informing
patients compassionately, and seeking patient understanding of that medical decision. A doctor can, and often does,
go against patient wishes for CPR/ACLS if the doctor believes the patient is not likely to survive. The practice in the
United Kingdom is not medical paternalism run amuck, but
instead is a well-reasoned practice, informed by the limits
of medicine. In the United Kingdom these decisions about
CPR/ACLS and who might survive are bounded by what
is medically feasible.
THE DOGMATICS OF FUTILITY
While it took years of experience before doctors would
begin to think about CPR/ACLS in terms of outcomes
January, Volume 10, Number 1, 2010
and to whom CPR/ACLS should be offered, as early as
1987 it had become clear that the outcomes of in-hospital
CPR/ACLS were poor (McGrath 1987). By 1994, lists began
to emerge categorizing those patients that did not benefit
from CPR/ACLS (Stewart et al. 1994). Eventually, nursing
journals would join the questioning of CPR/ACLS with
their own data (Hayward 1999). In addition, the British
Medical Association and Royal College of Nursing have
judiciously articulated that the option of CPR should be
withdrawn “where successful CPR is likely to be followed
by a length and quality of life which would not have been
acceptable to the patient” (Decisions Relating to Cardiopulmonary Resuscitation 1993; Birtwistle and Nielsen 1998). In
other words, sometimes CPR/ACLS is a pseudo-option and
should not be part of the panoply of choices offered to all
patients.
According to Helft, Siegler and Lantos (2000), use of
the concept of futility arose as an attempt to convince society that doctors were in the best position to make medical
judgments regarding patient treatments based on their clinical experience and prevailing medical evidence. The idea
then was that doctors could unilaterally decide when medical interventions would not be successful, i.e., futile, and
consequently determine whether and when they could be
administered and/or withdrawn.
However, these scholars also document the fall of futility as a tripartite collapse. First, the concept is very difficult
to define and like all attempts to define—which are also attempts at controlling the inherent ambiguity of medicine—
there are exceptions to the definition. Second, because of the
conceptual failure, empirical researchers began to gather a
base of evidence documenting survival rates for various
kinds of interventions. However, this evidence-based approach fails in the same manner that all evidence-based
approaches fail. After all, cardiopulmonary arrest is the final common pathway to death for all diseases. Thus, the
variability of causal mechanism and overall patient condition is too great to generalize, making prediction of success
and failure difficult. Moreover, knowing with even a small
degree of certainty whether the patient in the bed is likely to
be in the salvageable or lost category is virtually impossible.
Finally, Helft, Siegler, and Lantos (2000) note that the attack
on futility was pitched as patient’s right versus doctor’s
autonomy. Framed as a question of right—read, power—to
decide, and with the patient’s body hanging in the balance,
the tide turned in favor of patient decision making.
Thus, the concept of futility fails on theoretical (impossibility of definition) and practical grounds (lack of empirical
basis and universally predictable outcomes), as well as political grounds (doctor vs. patient power). Futility never had
a chance. A qualification on Helft, Siegler, and Lantos’s second reason for the failure of the concept of futility, namely,
the appeal to empiricism, is needed. There is no doubt that
the practical application of the concept of futility has fallen
victim to physician discomfort with the uncertainty inherent in the use of group-based statistics to predict outcomes
in particular patients. In other words, just because almost
all patients in a similar situation would die does not mean
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that this patient will die. In the same way, all medical judgments are potentially, indeed necessarily, fallible. This fact
was identified and explicated by Gorovitz and MacIntyre
years ago (1975). Physicians have learned to attenuate their
discomfort with this necessary fallibility through the use
of clinical experience, evidence-based medicine, and robust
definitions. But uncertainty in any decision, including those
about futility of treatment, cannot be reduced to zero, or
anything that remotely approximates zero.
While this form of uncertainty remains inherent in decisions regarding futility, a flawed conceptualization of prognosis remains in use that unnecessarily contributes to the
failure of futility on practical grounds. The ACLS protocols are structured as algorithms organized around immediately identifiable symptoms, such as pulselessness or absence of respiration. All interventions are based on treating
these symptoms, with only occasional attention given to the
proximate cause of the arrest, such as treating volume depletion. This structure has proven extraordinarily valuable,
as it allows providers to begin interventions immediately
with essentially no knowledge of the patient’s underlying
condition. However, because CPR/ACLS is routinely conceptualized by physicians and other providers using this
structure, the framework used to deal with the prognosis
of CPR/ACLS often follows the same pattern. As a result, much of the ward culture, and indeed much of the
research, regarding prognosis of CPR/ACLS has focused
on the symptoms, such as cardiac rhythm, noted at the time
of arrest or on the proximate cause of arrest, such as electrolyte disturbances (Sandroni et al. 2007).
This tendency to focus on symptoms or on proximate
causes has contributed to the failure of the concept of futility
in at least two ways. First, physicians have found it difficult to determine whether CPR/ACLS is practically futile
in individual cases because the factors receiving attention
impact primarily the immediate prognosis of the resuscitative measures, while having little to do with the longer term
prognosis (Skrifvars et al. 2007). Second, and intimately related to the first, the focus of ACLS protocols on symptoms and proximate causes has presented providers with
the opportunity to do something. An important schema in
the ethos of medicine is, (1) identify a problem, then (2)
treat the problem. Providers experience a great deal of discomfort when they see a problem that does not receive an
intervention. This discomfort has, among other outcomes,
led to the common unit practice of turning off monitors
when a patient who will not be resuscitated approaches
death.
A corrected conceptualization of prognosis in the setting of potentially futile treatment would focus instead on
the underlying disease process or, in other words, the distal
causes of arrest. Thus, if physicians focus on the more distal causes, if they focus on the lethal illness that results in
arrest, then futility might find some redemption as a useful
concept. Even if a patient carries a diagnosis of a terminal
disease for which the length of remaining life is unknown,
prognosis can be understood in terms of arrest as a marker
for the progression of disease.
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We want to make explicit that in proposing a reconceptualization of prognosis oriented toward distal causes
of arrest, we are focused primarily on the use of caregiver
judgment in the interpretation of available medical information. We are not proposing a new orientation for research
related to cardiopulmonary arrest. This stance certainly depends, as we have said, on the recognition of the necessary
fallibility in all medical decisions. No matter how much evidence we are able to gather, the ability to predict outcomes
with certainty will always be limited. Going further, however, we recognize cardiopulmonary arrest as the final common pathway in the process of death from all distal causes.
For this reason, the task of determining prognosis among
all combinations of distal and proximal causes of arrest in
patients of all ages and with all combinations of preexisting organ failure is practically impossible. We must keep
this post-modern reality in mind, then, as we reconsider the
value of the concept of futility.
POST-MODERN CRITIQUE OF FUTILITY
Notwithstanding this qualification of the scheme presented
by Helft, Siegler, and Lantos, there have been recent efforts to salvage the concept of futility on the whole because doctors continue to have an intuitive sense that not
all interventions work, and accordingly not all interventions
should be triggered at the patient’s discretion. These new
attempts, however, have also suffered the same fate as previous attempts at defining futility (Jecker 2007; Mohindra
2007). In our opinion, only one article, by John Paul Slosar
(2007), hits upon the real problem with futility, namely, that
it is an attempt to fix certainty in one value-laden structure
(medicine) over others in the public sphere.
Slosar frames his discussion in terms of the “postmodern” critique of futility, namely, that the claim of medical futility is based on the notion that medical futility is defensible when grounded in robust and rational definitions,
good statistics, and the best of clinical judgment. However,
for members of our society, moral values are heterogeneous,
and differing moral rationalities are equally defensible in a
public sphere that claims moral and political neutrality. Few,
if any, shared grounds for minimal rationality exist to which
one can appeal in today’s society. Slosar suggests that this
renders impossible any robust claim of medical futility. With
limited practical relevance, the concept of medical futility
just does not do the work that it claims to be able to do,
according to Slosar.
While we are in agreement with Slosar’s diagnosis, we
think he gets it wrong in terms of a response. We are in
agreement that there is little consensus and that all attempts
to find “cookbook” formulations of futility are themselves
futile. Still, that does not mean that the concept has limited practical value. The problem with futility and CPR and
DNR and indeed all medical decisions is the intractability
of making a medical decision at all. Physicians and families
would like to act with the confidence that their decisions
are correct. But as we have shown, the ability to act with
assurance in all cases is limited by the necessary fallibility
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of medical decisions. Going further, even once decisions
are made, the way forward depends on the competency of
providers to interpret clinical information, use clinical experience, and carry out plans, all without error. As a result,
all medical decisions are value laden and any claim to the
contrary is uninformed at best, and facetious at worst. In
short, everything about medicine is finite, just as life itself
is finite.
However, to admit finitude is to defeat the illusion of
confidence and certainty that medicine has nurtured to sustain social trust. In the end, medicine is a victim of its own
successes. All things from intensive care units to Botox injections are attempts to stave off death and its reminders,
giving society the optimistic illusion that in fact one does
not have to die. And the practice of presumed consent to
CPR applied universally in the hospital is a product of this
false optimism. The structures of contemporary medicine
certainly seem to want absolute certainty in a very messy
and uncertain world, an implicit quest for immortality, as
shown by Callahan (2000).
Rather than saying we live in a post-modern world and
certainty is not possible and, therefore, that the concept
of futility should be abandoned, we instead propose that
medicine must acknowledge and own its inherent uncertainties. Such candor on the part of the medical community
could begin with our admission that not all interventions are
medically feasible. We are victims of medicine’s successes,
and the unintended consequences for these successes are
practices like in-hospital universal, presumed consent to
CPR that result in patient expectations on which medicine
cannot deliver.
CONCLUSIONS AND FOUR RECOMMENDATIONS
We are therefore claiming that, like so many other structures
in medicine, the practice of in-hospital universal CPR is a
product of its historical time, when medicine’s technological optimism was ensconced in its policy structures; it is a
holdover of a time when medicine had an implicit quest for
immortality. In truth, CPR/ACLS is a medical intervention
with reasonable success in some kinds of patients with certain kinds of diseases. Furthermore, it must be remembered
that CPR/ACLS also has miserable success rates in certain
kinds of patients with some other kinds of diseases. A ward
culture insisting on presumed CPR acts as though there is
one entity, cardiopulmonary arrest, for which CPR/ACLS
is the answer.
DNR and DNAR orders are also distinct products of a
particular time in the history of medicine and were designed
to address the excesses that presumed consent to CPR engender. Historically, the DNR order was an attempt to keep
medicine from its implicit quest for immortality. The refusal
of a DNR order by a patient continues to operate under the
patient choice model—a model that perpetuates the falsehood that all deaths can be prevented and creates the odd
and false illusion that all deaths should be prevented.
Certainly patients have a right to refuse treatment, including CPR. Yet, even despite the legal protections that
January, Volume 10, Number 1, 2010
exist in most U.S. jurisdictions, doctors continue to think
that they must perform CPR/ACLS on patients who do not
refuse it, even when it is not medically indicated. For example, Spitzer’s interpretation of New York state law essentially ensconces in law the patient decision for CPR/ACLS
even when such interventions will not work to restore the
patient to health. In this instance, the refusal of the DNR
order becomes a means to coerce doctors into carrying out
medical interventions against their best medical judgment
and for which there may be no indication.
The fact that CPR and DNR (DNAR) orders are handled differently in different parts of the world is indicative
that U.S. medicine need not continue on its current historically constituted trajectory. Even though the United Kingdom maintains CPR and DNAR policies quite different from
those in the United States, it still provides very good care to
British subjects. Alternatives, therefore, are possible. Doctors in the United Kingdom make the decision regarding
what is or is not medically appropriate, and then they communicate their professional medical opinion to the patient.
CPR/ACLS is a medical decision that the patient can refuse,
but on which the patient cannot insist. Such a paradigm is
one we urge U.S. doctors to consider.
At the same time, we acknowledge that numerous barriers prevent a rapid transition from an environment of
presumed consent/obligation to perform resuscitation to
a practice more closely resembling that of the United Kingdom. Indeed, much will need to change in both the lay
perception of medical practice and the physician understanding of the goals and limitations of treatment in order
for the United States to deviate from its current course. As
with all efforts at cultural change, we must start with small,
simple changes in practice paired with improvements in education. Since it is our conviction that policy cannot change
culture, but rather that cultural change can lead to policy
change, we do not delineate a specific policy agenda. Instead, we want to propose the immediate steps that can lay
the groundwork for more substantive change in the long
term.
First, to the extent permissible under individual state
laws, we propose that U.S. hospitals and journals begin to
consider the term “do not resuscitate order” and the abbreviation “DNR” to be obsolete. These terms carry the implicit
message that when interventions such as chest compressions and bag-mask ventilation are undertaken, resuscitation of the patient will result. We favor the phrase “do not
attempt resuscitation” and the abbreviation “DNAR,” making clear that CPR is really only an attempt at resuscitation.
While we acknowledge the value of such proposed alternatives as “allow natural death,” we find that DNAR retains
clarity about the interventions being discussed while reminding both patients and practitioners of the uncertainty
of the outcome of resuscitative efforts.
Second, we suggest that medical education utilize an
extension of the classic medical mnemonic for admission orders, “ADC VAN DISMAL.” This mnemonic (and its countless variations) is used to remind medical learners and practitioners of the questions that must be answered at the time
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of admission to the hospital. ADC stands for “Admit to. . . ;
Diagnosis; Condition.” We propose that the mnemonic be
extended to “ADRC VAN DISMAL,” with the R representing “attempt to resuscitate.” Placing “attempt resuscitation”
status immediately after diagnosis reminds the practitioner
that the diagnosis of the patient should play a major role
in determining whether resuscitation should be attempted.
That is, attention should be paid not only to the proximate
event (cardiopulmonary arrest), but also to the underlying
diagnosis and disease process, and the associated prognosis. This modification in the admission orders also makes
the specification of “attempt resuscitation” and “do not attempt resuscitation” explicit. While some policies will at
first continue to presume consent for CPR, practitioners will
be reminded that there is a decision to be made. In addition,
this is a decision that, like other admission orders such as
diet and intravenous fluids, should be re-addressed daily
as the patient’s status changes (Holzapfel et al. 2002). A
patient who would not have survived a cardiac arrest last
week might do so today; a patient who could have initially
survived a code, now, after a week in hospital, with renal
failure and hypoxia, is not likely to do so.
Third, we agree with previous commentaries that discussions among physicians, patients, and families about
whether resuscitation is desired should be a routine part of
every hospital admission. For instance, Professor Boozang
suggests elimination of any notions of presumed consent to
CPR in favor of a conventional informed consent conversation when the patient is admitted (Boozang 1993). Boozang
argues that compelling physicians to raise resuscitation with
patients and share realistic information about survival in
the context of a general discussion about end-of-life treatment will promote mutual patient–physician interaction,
help lower patient expectations of CPR, and facilitate the development of a comprehensive and appropriate treatment
plan consistent with “the patient’s goals, values, diagnosis, and prognosis” (Boozang 1993). However, we would
add that as a routine part of this discussion the physician
should provide an explanation of how the patient’s prognosis would change should the patient experience cardiopulmonary arrest. A cardiopulmonary arrest is not a neutral
event. It is thus not only indicative of the severity of illness,
but also an indicator that the prognosis is worse than if the
cardiopulmonary arrest had not happened. A discussion of
these features can be of particular value to families of patients for whom an event of cardiopulmonary arrest would
indicate a worsening of the underlying disease or result
in irreversible damage. Although the practice of presumed
consent to CPR outside the hospital falls outside the scope
of this paper, suffice it to say that the decision to utilize CPR
looks very different on the street or at the door of the emergency department, where it may be impossible to discern
the distal cause of arrest.
Fourth, physicians should help clarify prognosis by
proposing a course of action to the family. In some instances, that will mean deferring to patient decision, where
the medical evidence and judgment is not conclusive. In
other situations, it will mean recommending that CPR not
66 ajob
be attempted. Consistent with safeguards ensuring physician accountability and where individual state laws would
permit broad physician discretion, it might even mean that
some cases will necessitate reclassifying CPR as a pseudooption that does not even warrant a mention. In the United
States, the same culture that views a unilateral decision on
the part of the physician to make a patient DNAR as paternalistic may feel discomfort with a physician even recommending that a DNAR order be placed. However, a failure
to make a recommendation is more likely to cause families
additional anxiety than it is to be perceived as coercion. In
addition, making a proposal for a course of action can help
a physician communicate the significance of a cardiopulmonary arrest given the patient’s underlying condition.
As noted, these four recommendations are only the first
steps along a process of cultural change. The ultimate goal
will be to reach a more balanced place where discussions
about decisions can be made jointly, but with the acknowledgment that all decisions are laden with moral values inherent in the practice of medicine and life in a pluralistic
society, and that all judgments are themselves fallible. In
short, we hope to stimulate discussions within both the
medical community and the non-medically trained population where with openness and honesty doctors and patients can explore the fallibility of medical decisions and
judgments and the limitations of what is medically feasible.
This might be a step in the right direction at letting go of
the implicit quest for immortality, and placing CPR/ACLS
in its proper place among clinical interventions that are not
offered or expected in all cases because they are not relevant
to the clinical condition of the patient. REFERENCES
Annas, G. J. 1982a. CPR: The beat goes on. Hastings Center Report
12(4): 24–25.
Annas, G. J. 1982b. CPR: When the beat should stop. Hastings Center
Report 12(5): 30–31.
Baker, R. 1995. The 1988 DNR reforms: A comparative study of the
impact of the New York DNR law and the JCAHO accreditation
requirements. In Legislating medical ethics: A study of the New York
State do-not-resuscitate law, ed. R. Baker, M. A. Strosberg, and J.
Bynum, 263–302. Boston, MA: Kluwer Academic.
Birtwistle, J., and A. Nielsen. 1998. Do not resuscitate: An ethical
dilemma for the decision-maker. British Journal of Nursing 7(9): 543–
549.
Blackhall, L. J. 1987. Must we always use CPR? New England Journal
of Medicine 317(20): 1281–1285.
Boozang, K. M. 1993. Death wish: Resuscitating self-determination
for the critically ill. Arizona Law Review 35(1): 23.
Bryan v. Rectors of the University of Virginia. 1996. 3rd Circuit.
Callahan, D. 2000. The troubled dream of life: In search of peaceful death.
Washington, DC: Georgetown University Press.
Carson, R. A., and M. Siegler. 1982. Does ‘doing everything’ include
CPR? Hastings Center Report 12(5): 27–29.
January, Volume 10, Number 1, 2010
Reviving the Conversation Around CPR/DNR
Decisions Relating to Cardiopulmonary Resuscitation—A Statement
from the BMA and RCN in Associated with the Resuscitation Council
UK. 1993. London: British Medical Association and Royal College
of Nursing.
General Medical Council. 2002. GMC Guidance on withholding and
withdrawing life-prolonging treatments: Good practice in decisionmaking. Available at: http://www.gmc-uk.org/guidance/
current/library/witholding lifeprolonging guidance.asp#
Cardiopulmonary resuscitation, accessed August 8, 2007.
Gorovitz, S., and A. MacIntyre. 1975. Toward a theory of medical
fallibility. Hastings Center Report 5(6): 13–23.
Hayward, M. 1999. Cardiopulmonary resuscitation: Are practitioners being realistic? British Journal of Nursing 8(12): 810–814.
Downloaded by [71.164.83.226] at 12:11 09 February 2016
Helft, P. R., M. Siegler, and J. Lantos. 2000. The rise and fall of
the futility movement. New England Journal of Medicine 343(4): 293–
296.
Hofmann, P. B., and L. J. Schneiderman. 2007. Physicians should not
always pursue a good “clinical” outcome. Hastings Center Report
37(3): inside back cover.
Holzapfel, L., G. Demingeon, B. Piralla, L. Biot, and B. Nallet. 2002.
A four-step protocol for limitation of treatment in terminal care.
An observational study in 475 intensive care unit patients. Intensive
Care Medicine 28(9): 1309–1315.
Jecker, N. S. 2007. Medical futility: A paradigm analysis. HEC Forum
19(1): 13–32.
Jonsen, A. R. 1998. The birth of bioethics. New York: Oxford University Press.
Jude, J. R., W. B. Kouwenhoven, and G. G. Knickerbocker. 1961a.
Cardiac arrest. Report of application of external cardiac massage on
118 patients. Journal of the American Medical Association 178: 1063–
1070.
Jude, J. R., W. B. Kouwenhoven, and G. G. Knickerbocker. 1961b.
A new approach to cardiac resuscitation. Annals of Surgery 154(3):
311.
Kamer, R. S., and J. A. McClung. 1995. New York’s do-notresuscitate law: Burden or Benefit? In Legislating medical ethics: A
study of the New York State do-not-resuscitate law, ed. R. Baker, M. A.
Strosberg, and J. Bynum, 227–234. Boston, MA: Kluwer Academic.
Kouwenhoven, W. B., J. R. Jude, and G. G. Knickerbocker. 1960.
Closed-chest cardiac massage. Journal of the American Medical Association 173: 1064–1067.
Kouwenhoven, W. B., and J. H. Kay. 1951. A simple electrical apparatus for the clinical treatment of ventricular fibrillation. Surgery
30(5): 781–786.
Layson, R. T., and T. McConnell. 1996. Must consent always be
obtained for a do-not-resuscitate order? Archives of Internal Medicine
156(22): 2617–2620.
M.D. Code Ann. 2009. Health-Gen. 5–611 Law.
McArdle, E. F. 2002. New York’s do-not-resuscitate law: Groundbreaking protection of patient autonomy or a physician’s right to
January, Volume 10, Number 1, 2010
make medical futility determinations? DePaul Journal of Health Care
Law 6(1): 55–82.
McGrath, R. B. 1987. In-house cardiopulmonary resuscitation—
After a quarter of a century. Annals of Emergency Medicine 16(12):
1365–1368.
Mohindra, R. K. 2007. Medical futility: A conceptual model. Journal
of Medical Ethics 33(2): 71–75.
Moore, P. 2007. End-of-life quandary in need of a statutory response:
When patients demand life-sustaining treatment that physicians
are unwilling to provide. Boston College Law Review 48: 433–470.
Muller, J. H. 1992. Shades of blue: The negotiation of limited codes
by medical residents. Social Science & Medicine 34(8): 885–898.
N.Y. Public Health Law. April 1, 1998. Art. 29-B, Section 2960.
N.Y. Public Health Law. 2009. Art. 29-B, Section 2962.
Pope, T. M. 2007. Medical futility statutes: No safe harbor to unilaterally refuse life-sustaining treatment. Tennessee Law Review 75(1):
1–81.
Rabkin, M. T., G. Gillerman, and N. R. Rice. 1976. Orders not to
resuscitate. New England Journal of Medicine 295(7): 364–366.
Sabatino, C. P. 1999. Survey of state EMS-DNR laws and protocols.
Journal of Law, Medicine & Ethics 27(4): 297–315.
Sandroni, C., J. Nolan, F. Cavallaro, and M. Antonelli. 2007. Inhospital cardiac arrest: Incidence, prognosis and possible measures
to improve survival. Intensive Care Medicine 33(2): 237–245.
Skrifvars, M. B., M. Castren, J. Nurmi, A. B. Thoren, S. Aune, and
J. Herlitz. 2007. Do patient characteristics or factors at resuscitation
influence long-term outcome in patients surviving to be discharged
following in-hospital cardiac arrest? Journal of Internal Medicine
262(4): 488–495.
Slosar, J. P. 2007. Medical futility in the post-modern context. HEC
Forum 19(1): 67–82.
Smith, G. P. II. 2000. Euphemistic codes and tell-tale hearts: Humane
assistance in end-of-life cases. Health Matrix: Journal of Law-Medicine
10: 175–203.
Spitzer, E. 2003. New York Attorney General opinion no. 2003-F1.
Stewart, K., A. Wagg, and M. Kinirons. 1994. Does audit improve
DNR decision making? Journal of the Royal College of Physicians,
London 28(4): 318–321.
Tex. Health & Safety Code Ann. 2003. Section 166.052.
Tomlinson, T., and H. Brody. 1990. Futility and the ethics of resuscitation. Journal of the American Medical Association 264(10): 1276–1280.
V.A. Code Ann. 2000. Section 54.1.2990.
Wilder, R. J., J. R. Jude, W. B. Kouwenhoven, and M. C. McMahon. 1964. Of 153 attempted—Cardiopulmonary resuscitations by
trained ambulance personnel—No fatal injuries were produced.
Journal of the American Medical Association 190: 531–534.
Zoch, T. W., N. A. Desbiens, F. DeStefano, D. T. Stueland, and P. M.
Layde. 2000. Short- and long-term survival after cardiopulmonary
resuscitation. Archives of Internal Medicine 160(13): 1969–1973.
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