Should we allow natural death?
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Acceptance for death has become extremely rare among patients and caregivers. Situation is grave in Indian hospitals.
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Should we allow natural death?
- 1. Z-66
- 2. . After series of acute deaths following to devastating haemorrhagic strokes and ineffectiveness of sham ventilation after futile CPR, we evoked discussion about allowing natural death and make policy about “Do Not Resuscitate” order. Indian law is silent about futility of resuscitation in terminally ill patients. There is no documented cases of negligence due to failure of cardiopulmonary resuscitation. Yet there is serious disagreement and confusion among caregivers across the Indian Hospitals.
- 3. Origin of CPR 1960s - Anesthesiologists did CPR on adults and children who suffered from witnessed cardiac arrest following reversible illnesses and injuries. CPR became the standard of care for all etiologies of cardiopulmonary arrest and the universal presumptive consent to resuscitation evolved
- 4. Is CPR always beneficial? 1974, the American Heart Association (AHA) recognized that under certain circumstances, CPR may not offer the patient direct clinical benefit the resuscitation will not be successful or will lead to co-morbidities that will merely prolong suffering without reversing the underlying disease. AHA Recommended that physicians document in the chart when CPR is not indicated after obtaining patient or surrogate consent. This documentation formally became known as the DNR order
- 5. Defining Direct Medical Benefit – Outcome of CPR In Hospital Cardiac Arrest Adult survival rates - 8-39% and favorable neurological outcome in 7-14% Children Survival rate 27% with a favorable neurological outcome in 20% Out of hospital Cardiac arrest Adult 7-14% and Infants and children 3-9%
- 6. When can CPR be withheld? Futile CPR When CPR cannot reverse the on‐going dying process or Will not provide therapeutic benefits that outweigh the harms or substantial burdens of CPR Refusal of CPR by competent adult patients
- 7. Are DNR Ethically Acceptable ? “It is widely recognized by health care professionals, clergy, lawyers and others that DNR orders are medically and ethically appropriate under certain circumstances.”
- 8. How are DNAR Orders Written? Prior to writing a DNAR Order, physicians should discuss resuscitation preferences with the patient or his/her surrogate decision maker 1. Why and how the initial question of resuscitation status was raised. 2. Decision making process which has been and will be followed: a. Professional staff involvement; b. Role of parents and patient; c. Data upon which decision is based. 3. Summary and update of planning process and decision. 4. Summary of conversations with patients and parents.
- 10. If CPR is "futile," should a DNAR order be written? “If health care providers unanimously agree that CPR would be medically futile, clinicians are not obligated to perform it.”
- 11. What if CPR is not futile, but the patient wants a DNAR order? This position stems from respect for autonomy, and is supported by law in many states that recognize a competent patient's right to refuse treatment.
- 12. What if the family disagrees with the DNAR order? Obtain a second opinion or transfer the patient unless the patient’s condition precludes doing so. Clinical staff are not required to perform physiologically futile and harmful treatments on a patient. Review
- 13. What are CPR mimics? Slow Codes - is an act that resembles CPR yet is not the full effort of resuscitation. Show code - is a short and vigorous resuscitation performed to benefit the family while minimizing harm to the patient. Comfort Care - only comfort care be administered before, during, or after the time a person’s heart or breathing stops Comfort Care-Arrest - the use of life-saving measures (such as powerful heart or blood pressure medications) before a person’s heart or breathing stops.
- 14. Special Circumstances Children Surgical Procedures Emergency Medical Technician
- 15. When to Discontinuation of a DNR Order? A DNR order may be revoked by a competent patient or surrogate decision‐maker, unless it is futile or non therapeutic Discontinuation of the DNR order must be documented
- 16. Living Will? A person of sound mind can himself instruct the doctors to withdraw life support measures. Doctors would be bound by such instructions. If they persist with such measures, they would be committing an illegality for which the patient or his LRs can sue the doctor. However, this must be properly documented with, preferably, the LRs / attendants being a witness to such instructions. A person of sound mind can also instruct those concerned in advance through a living will not to start or to withdraw life support measures. Doctors would be bound by such instructions. Dr. M C Gupta (Former Professor and Dean) MD (Medicine), LLM Advocate (Delhi Bar Council no. 857/2001)
- 17. Like any serious medical procedure CPR should be performed judiciously to prevent burden of morbidity and expenditure to the caregivers . “We should Accept Natural Death”
Editor's Notes
- This presentation is a discussion about Accepting Natural Death based on existing practice in other countries and may not be taken as reference in court of law.
- After series of acute deaths due to devastating hemorrhagic strokes and ineffectiveness of sham ventilation after futile CPR we evoked discussion about allowing natural death and make policy about “Do Not Resuscitate” order. Indian law is silent about futility of resuscitation in terminally irreversible conditions. There is no documented cases of negligence has arrived due to failure of cardiopulmonary resuscitation. Yet there is serious disagreement and confusion among caregivers across the Indian Hospitals.
- In the 1960s, CPR was initially performed by anesthesiologists on adults and children who suffered from witnessed cardiac arrest following reversible illnesses and injuries. Based on the success of this intervention, CPR became the standard of care for all etiologies of cardiopulmonary arrest and the universal presumptive consent to resuscitation evolved (Burns et al., 2003).
- Determining the potential for direct medical benefit can be challenging, especially when there is great uncertainty in outcome. One approach to defining benefit examines the probability of an intervention leading to a desirable outcome. Outcomes following CPR have been evaluated in a wide variety of clinical situations. In general, survival rates in adults following in-hospital cardiac arrest range from 8-39% with favorable neurological outcomes in 7-14% of survivors (Meaney et al., 2010). In children, the survival rate following in-hospital cardiac arrest is closer to 27% with a favorable neurological outcome in up to one third of survivors (AHA, 2010). Out of hospital arrest is less successful, with survival rates in adults ranging from 7-14% and in infants and children approximately 3-9% (Meaney et al., 2010; Garza et al., 2009). In general, these statistics represent the population as a whole and do not necessarily reflect the chance of survival for an individual patient. Hence, multiple factors, including both the distal and proximal causes for cardiopulmonary arrest, must be considered to determine whether or not CPR has the potential to promote survival (Bishop et al., 2010). CPR might appear to lack potential benefit when the patient's quality of life is so poor that no meaningful survival is expected even if CPR were successful at restoring circulatory stability. However, quality of life should be used with caution in determining whether or not CPR is indicated or has the potential to provide medical benefit, for there is substantial evidence that patients with chronic conditions often rate their quality of life much higher than would healthy people. Quality of life assessments have most credibility when the patient’s values, preferences, and statements inform such assessments.
- ARE DNR ORDERS ETHICALLY ACCEPTABLE ? It is widely recognized by health care professionals, clergy, lawyers and others that DNR orders are medically and ethically appropriate under certain circumstances. For some patients, CPR offers more burdens than benefits, and may be against the patient's wishes. I. Ethical Concerns The Hospital Ethicist and Ethics Advisory Committee are available to any member of the health care team, family, and patient, for advice about ethical concerns, including decisions about resuscitation or other life‐sustaining treatments. The Office of Ethics can be reached at x6920 and an Ethicist is always available by pager. J. Legal Considerations If clinical staff believe legal consultation is necessary or might prove helpful, an attorney with the Hospital’s Office of General Counsel should be contacted at x6800 or, if urgent, by pager. For example, when a child is in state custody through Massachusetts Department of Children and Families, an ethics committee consultation and court review of decisions to limit life‐sustaining treatments is legally required. Hospital counsel might also be consulted when guardians or attorneys are involved on behalf of the child and/or parent(s), or when there are concerns about conflict, consent or documentation.
- Prior to writing a DNAR Order, physicians should discuss resuscitation preferences with the patient or his/her surrogate decision maker (Blinderman et al., 2012; Quill et al., 2009). This conversation should be documented in the medical record, indicating who was present for the conversation, who was involved in the decision making process, the content of the conversation, and the details of any disagreement. These conversations are difficult and involve a careful consideration of the potential likelihood for clinical benefit within the context of the patient's preferences. Physicians can most effectively guide the conversation by addressing the likelihood of direct benefit from cardiopulmonary resuscitation within the context of the overall hopes and goals for the patient. They can then partner with the patient and his or her family to determine the clinical interventions that most effectively achieve these goals (Blinderman et al., 2012). This approach is described by the palliative care literature as a goal oriented approach to providing end of life care. C. Documentation of a Do Not Resuscitate (DNR) order Documentation in the patient’s medical record of a decision not to do CPR must include both a Physician’s Order and an entry in the Progress Notes. Use of the standardized DNR Order Form is preferred, but is not required in cases where the attending physician prefers a narrative method of documentation. Documentation in the Progress Notes should include the following and be written or co‐signed by the attending physician: 1. Why and how the initial question of resuscitation status was raised. 2. Decision making process which has been and will be followed: a. Professional staff involvement; b. Role of parents and patient; c. Data upon which decision is based. 3. Summary and update of planning process and decision. 4. Summary of conversations with patients and parents. Subsequent progress notes should document re‐evaluation of the patient’s condition on a timely basis, continued appropriateness of the DNR order, and family involvement. Discussion(s) regarding resuscitation status with the patient and/or family are the responsibility of the attending physician. The Physician’s Order, whether utilizing the standardized form or a narrative format, must be signed by an attending physician and nurse. When the patient’s attending physician is not immediately available to sign the order, then a house staff physician may sign the order, after conferring with the attending physician over the phone to verify the appropriateness of the order, and document this conversation in the chart. Under these circumstances, the attending physician must physically sign the form as soon as possible and in any case no later than 24 hours after the order is entered into the patient’s medical record. In addition, an expiration date, if any, should be set forth in the orders.
- If health care providers unanimously agree that CPR would be medically futile, clinicians are not obligated to perform it. Nevertheless, the patient and/or their family still have a role in the decision about a Do Not Attempt Resuscitation (DNAR) order. As described earlier, involving the patient or surrogate decision maker is essential to demonstrate respect for all people to take part in important life decisions. In many cases, patients or surrogate decision makers will agree to forgo attempting CPR following a transparent and honest discussion regarding the clinical situation and the limitations of medicine. Under these circumstances, DNAR orders can be written. Each hospital has specific procedures for writing a valid DNAR order.
- In some cases, patients may request their desire to forgo attempting CPR at the time of admission. Some of these patients may have an advanced care directive that indicates their preferences to forgo attempting CPR. In other cases, a patient may explicitly request CPR not to be performed. If the patient understands her condition and possesses intact decision making capacity, her request should be honored. This position stems from respect for autonomy, and is supported by law in many states that recognize a competent patient's right to refuse treatment.
- Ethicists and physicians are divided over how to proceed if the family disagrees with the recommendation to forgo attempting CPR. If there is disagreement, every reasonable effort should be made to clarify questions and communicate the risks and potential benefits of CPR with the patient or family. In many cases, this conversation will lead to resolution of the conflict. However, in difficult cases, an ethics consultation can prove helpful. D. Entry of DNR order in cases of disagreement between clinical staff and parent(s) In almost all circumstances, parents and clinical staff should reach agreement about whether a DNR order is appropriate for the patient based on the patient’s prognosis, the risks of harm and potential benefits, if any, that may be expected of CPR, and the values of the parent(s) and patient. Nevertheless, on rare occasions, parents may request CPR even though the clinical team has concluded that CPR is either physiologically futile or not therapeutic. The process for dealing with such disagreements depends on the reason CPR is considered inappropriate. When there is agreement among clinical staff caring for the patient (i.e. the clinical team) that CPR is physiologically futile, parents should be informed and told that a DNR order will be written in the chart. Parents who disagree with the clinical decision not to do CPR should be given a reasonable opportunity to obtain a second opinion or transfer the patient unless the child’s condition precludes doing so. Clinical staff are not required to perform physiologically futile and harmful treatments on a patient. When there is agreement among clinical staff caring for the patient that CPR is non‐therapeutic and that performing CPR violates their medical‐ethical duty to the patient, and if parents still want CPR to be performed, the clinical team should initiate a process of review to determine whether a DNR order may be entered despite the disagreement of the parent(s). E. Process for reviewing disagreements about whether CPR is therapeutic If the patient’s clinical team has concluded that performing CPR on the patient would not be therapeutic, and if the team has been unable to reach agreement with the parents about entering a DNR order, then staff and/or parents should initiate the following review process: a. The clinical staff should confirm that members of the patient’s clinical team are in agreement that CPR should not be performed on the patient because it is non‐ therapeutic. b. A second opinion should be obtained from a physician not on the patient’s clinical team about whether CPR is non therapeutic. c. If the second opinion supports the conclusion of the clinical team, a member of the clinical team should contact the Ethics Office to schedule an ethics consult. d. Hospital staff will work actively with the patient’s parent(s) and other care providers (such as the patient’s primary care physician, school nurses, group home staff, etc.) to appreciate their concerns and plan for care without CPR. e. If the ethics consult supports entry of a DNR order despite the parents’ disagreement, the clinical staff should inform the Chief of Service and the Legal Office. f. If the Service Chief concurs, and if the legal office confirms that judicial involvement is not necessary, the parents should be told that a DNR order will be entered into the patient’s medical record. g. Parents should be given a reasonable opportunity and assistance to transfer the patient to another facility willing to accept the patient. h. If it is not possible to transfer the patient, a DNR order may be entered into the patient’s medical record.
- Slow codes and show codes are forms of “symbolic resuscitation.” A “slow code” is an act performed by the health care providers that resembles CPR yet is not the full effort of resuscitation while a “show code” is a short and vigorous resuscitation performed to benefit the family while minimizing harm to the patient (Frader et al., 2010). Slow and show codes are ethically problematic. In general, performing slow and show codes undermines the rights of patients to be involved in clinical decisions, is deceptive, and violates the trust that patients have in health care providers. 1) DNR Comfort Care DNR Comfort Care orders (DNRCC) require that only comfort care be administered before, during, or after the time a person’s heart or breathing stops. This type of order is generally regarded as proper for a patient with a terminal illness, short life expectancy, or with little chance of surviving CPR. 2) DNR Comfort Care-Arrest DNR Comfort Care-Arrest orders (DNRCC-Arrest) permit the use of life-saving measures (such as powerful heart or blood pressure medications) before a person’s heart or breathing stops. However, only comfort care may be provided after a person’s heart or breathing stops. 3) DNR Specified Valid only at Cleveland Clinic hospitals, DNR Specified orders are uniquely tailored by your physician. They may permit the use of some CPR treatment methods (such as powerful medications) while possibly prohibiting other methods (such as electric shock). All three options are available to you if you are hospitalized in a Cleveland Clinic hospital. The first two types of DNR orders can be changed to outpatient DNR orders when you leave the hospital. If you are an outpatient, the first two types of DNR orders can be written for you, but not the third type. If you are considering having a DNR order written, you should discuss these options with your physician to determine which DNR order might be best for you, given your medical condition.
- There are special circumstances that should be considered and addressed in patients with Do Not Attempt Resuscitation Orders. These circumstances primarily arise when a patient undergoes anesthesia for surgical interventions or requires urgent procedures. B. Role of Patient and Parents of Minor Children The patient and parents (or legal guardian) should be involved in making decisions about CPR. As with other clinical decisions, parents of minor children should be fully informed about medical recommendations regarding CPR and DNR, and minor children should participate to the fullest extent of their developmental abilities and emotional state. Generally, a DNR order should not be entered into the patient’s medical record without concurrence of the parents. However, a DNR order may be entered by the patient’s physician without parental permission if CPR is determined to be physiologically futile or non‐therapeutic, in accordance with Paragraphs E and F below. G. Patients who are 18 or Older As a general rule, patients who are 18 years of age or older are entitled to make decisions on their own behalf. However, in certain cases, when children over the age of 18 are not able to make their own decisions (are “incapacitated”), parents may be authorized to make decisions on their behalf. 1. Parents of children who are mentally incapacitated may have been given authority by the court to serve as guardians for their children. 2. Parents may have been designated health care agents or proxies in their adult child’s advance directive after the child turned 18, and thus are authorized to make decisions when their child is no longer capable of doing so. 3. In certain circumstances, even absent a court order or an advance directive, parents may be the appropriate surrogates for their adult child (just as a spouse or child may be the appropriate surrogate for an adult who has not completed an advance directive). By way of example, parents of a child with a chronic, degenerative illness may be the appropriate surrogate for their child in the event a decision must be reached about DNR and the child no longer has decision‐making capacity (but did not complete an advance directive). Parents may also be the appropriate surrogates for a child over 18 who become ill or injured unexpectedly and is unable to make decisions on his/her own behalf. Legal counsel should be contacted in these circumstances. F. Mandatory Reassessment of DNR Orders Before Anesthetic and Surgical Procedures Patients with DNR orders may be appropriate candidates for anesthesia and surgery, especially for procedures intended to facilitate care or relieve pain. The etiologies and outcomes of cardiac arrest during anesthesia are sufficiently different from those in non‐surgical settings that re‐evaluation of the DNR order is always necessary. The fact that cardiac arrest is more likely to be reversible when it occurs during anesthesia will often mean that it is in the patient’s best interest to have the DNR order suspended during the intra‐operative and immediate postoperative periods. In some cases, however, patients or their parents may desire limitations on the resuscitative procedures used throughout the perioperative period. The administration of anesthesia necessarily involves some practices and procedures that might be viewed as “resuscitation” in other settings. For example, routine anesthetic care usually requires placement of an intravenous catheter, administration of intravenous fluids and medications, and management of the patient’s airway and respiration. Chest compressions and electrical cardio‐version, on the other hand, are generally not intrinsic to the anesthetic or surgical procedure. The anesthesiologist, in conjunction with the patient’s other attending physicians, is responsible for discussing these issues with the patient and/or family, reassessing the patient’s DNR status prior to surgery, and communicating these decisions to those who will be involved with the patient’s care during the intra‐operative and immediate post‐operative period. The hospital’s standardized DNR Order form may not be the best tool for considering and documenting DNR status during the perioperative period. Alternatively, agreement with the patient and/or family on one of the following three options may meet the needs of most patients with DNR status who require anesthesia and surgery: K. DNR orders for Emergency Medical Technicians (EMTs) The Massachusetts Department of Public Health’s Office of Emergency Medical Services has developed the COMFORT CARE DNR Verification program to provide a mechanism for EMTs and First Responders to identify patients who have DNR orders and to initiate a protocol focused upon comfort and palliative care rather than automatic emergency CPR. The patient’s DNR status is indicated by a standardized state form that must be immediately available to EMS personnel and/or an orange bracelet on the patient’s arm. The attending physician is responsible for determining whether a patient needs a DNR verification order and for completing the CC/DNR Form and Bracelet, providing a copy for the parent(s) and placing a copy of the CC/DNR form in the patient’s medical record. The appropriate forms and informational brochures are available on the Critical Care units, or may be obtained from the MICU Office (x7327), the Office of Ethics (x6920), the Office of General Counsel (x6800), or online at http://www.mass.gov/eohhs/provider/guidelines‐resources/clinical‐treatment/comfort‐care/ Since the CC/DNR program applies only to EMTs and First Responders, the attending physician may also want to provide a statement on the physician’s letterhead and/or a copy of the Children’s Hospital DNR form to provide nonbinding guidance to others who may need information regarding the patient’s resuscitation status, such as visiting nurses or emergency physicians at Children’s Hospital or other institutions. As a general rule, valid CC/DNR Forms or Bracelets will be honored by the medical and nursing staff of Children’s Hospital Emergency Department and in the Children’s Hospital Ambulatory Clinics.
- H. Discontinuation of a DNR Order A DNR order may be revoked by a competent patient or surrogate decision‐maker, unless the DNR order has been entered because CPR is physiologically futile, or because it has been determined to be non therapeutic, provided the review process set forth in Paragraph E has supported such determination. Any member of the clinical staff or family may request that a DNR order be re‐evaluated. Discontinuation of the DNR order must be noted in the appropriate place on the DNR Order Sheet (or documented in the Physician’s Orders if a DNR Order Sheet is not used), and explained in the Progress Notes.