Documente Academic
Documente Profesional
Documente Cultură
o-not-resuscitate (DNR) orders are commonly found in treatment plans for patients near
the end of life. Orders for partial resuscitation (eg, do not intubate) have evolved from
DNR orders. Although the ethics of DNR orders have been widely examined in the medical literature, little has been written about the ethics of partial resuscitation. This article
explores the ethical implications of partial DNR orders and identifies the need to develop care plans
addressing life-threatening conditions for patients with DNR orders.
Arch Intern Med. 2003;163:2270-2275
Do-not-resuscitate (DNR) orders prohibit the use of interventions to reverse a
cardiac or pulmonary arrest.1-5 Typically,
these orders refer to the entire range of resuscitative efforts including basic life support and advanced cardiac life support.
Writing formal DNR orders is a relatively
new practice, having first appeared in
the MEDLINE-referenced literature in
the early 1980s.6,7 Orders for partial DNR
(eg, cardiac DNR or do-not-intubate orders) have more recently entered the
hospital vernacular and are directives
through which a patient receives some,
but not all, of the discrete elements of cardiopulmonary resuscitation (CPR).8-11 For
example, a do-not-intubate order permits cardiac resuscitation but prohibits endotracheal intubation for cardiopulmonary arrest. A chemical code refers to
resuscitative attempts limited to the use
of medications.10,12 Of all DNR orders,
probably fewer than 10% stipulate limited resuscitation.13 Limited data that are
available evidence dismal survival rates
among recipients of partial resuscitation.13 This finding is expected, given the
well-established relationship between rapidity of successful resuscitation and
clinical outcomes.14-18 Order writing for
this often ineffective treatment has gen-
From Winthrop University Hospital, Mineola, NY, and State University of New York,
Stony Brook School of Medicine, Stony Brook. The author has no relevant financial
interest in this article.
(REPRINTED) ARCH INTERN MED/ VOL 163, OCT 27, 2003
2270
WWW.ARCHINTERNMED.COM
DNR decisions.21-23 No studies describe physicians motivation, intent, or expectations for outcome
when these physicians authorize partial resuscitation. We do not know
who among physicians, patients, and
families advocate for partial DNR orders rather than full DNR orders. Although the presence of a DNR order tends to influence clinical
approaches to nonarrest conditions,24-27 it is unclear how physicians define the scope and utility of
full and partial DNR orders.
USE OF PARTIAL DNR ORDERS
Partial DNR orders affect treatment
of actual cardiopulmonary arrests as
well as treatment of life-threatening nonarrest conditions, for which
only some intensive interventions
are desired. In either case, partial
DNR orders are often clinically perplexing and ethically problematic.
Partial DNR Orders
to Direct Care for Cardiac or
Pulmonary Arrests
With only particular exception, partial attempts to reverse a cardiac or
pulmonary arrest are medically unsound because these interventions
are often highly traumatic and consistently inefficacious.13 Partial resuscitation generally violates ethical obligations of nonmaleficence,
that is, to avoid disproportionate patient harms.28 Rarely, cardiac resuscitation alone, written as pulmonary DNR or do-not-intubate
orders, may be appropriate when
cardiac and respiratory arrests are
pathophysiologically distinct and
prognosis is good with cardiac resuscitation alone. For example, malignant arrhythmias in the perimyocardial infarction period may be
quickly and successfully treated with
electrical cardioversion before the
airway can be, or needs to be, secured by intubation. Patients who
wish never to be intubated may accept this plan. This treatment is ethically supportable because it is reasonably efficacious in meeting a
medically acceptable, patientdefined care goal.
Respiratory resuscitation alone,
written as cardiac DNR, is generally inappropriate for cardiopulmo-
WWW.ARCHINTERNMED.COM
intensive care settings, the practical question is whether to treat the physiologic abnormalities . . . after a DNR order is written . . . if untreated, these abnormalities
could lead to cardiopulmonary arrest.
Third, informed patients may reject some
forms of . . . life support while accepting
others.
However, neither DNR nor partial DNR orders are intended to communicate complex end-of-life care
plans, and they clarify little about patients goals of care.
Efforts to fill this gap have been
reported. The values history48 assists in recording patients broad
quality-of-life goals but serves poorly
as action guides. Conversely, instruments offering checklists of the discrete elements of CPR are specific action guides.9,49,50 However, they can
facilitate orders for medically unsound treatment compositions (eg,
treating malignant arrhythmias with
chest compressions alone) and are
generally inattentive to goals of
care.51,52 Although these directive
tools may reduce interprofessional
variability regarding treatment of patients with DNR orders, they do not
necessarily promote appropriate
care.
Use of partial DNR orders
should be avoided (no intubation orders may be used to supplement
DNR orders when intubation for
nonarrest respiratory conditions is
also inappropriate). Rather, physicians should collaborate with each
patient or surrogate for whom a DNR
order is written to develop supplemental information supporting a
care plan that addresses treatment of
life-threatening conditions. This care
plan should contain the following 5
elements:
1. Identification of patients
treatment goals: Patients or patients surrogates should describe
their broad health care objectives,
with guidance from their health professionals. Clarification of these goals
is fundamental to developing patient-relevant and medically coherent treatment plans.51 Patients who
consent to DNR orders may define
goals of care as symptom palliation
alone; the pursuit or maintenance of
a specific quality of life (commonly
determined by a particular cognitive or functional ability); or as preservation of life regardless of qual-
WWW.ARCHINTERNMED.COM
Purpose
Description/Example
1. Patient goals
3. Physician discretion
5. Easily transmittable
are now considerably lower, and dialogue between the physician the surrogate is needed to assess how evolving probabilities of outcome intersects
with changing treatment-associated
burdens.
4. Care plan must link patients
or surrogates requests for specific treatments to goals of care to avoid medically inappropriate combinations of
medical interventions: Patients or surrogates particular requests for endof-life treatments sometimes may be
unsound (eg, declining dialysis for
acute renal failure but requesting mechanical ventilation for the consequent acidosis-induced tachypnea).
These treatment declination/request
associations must correlate with the
patients goal of care so that treatment remains patient centered and
not misdirected by social, emotional, or other concerns.
5. Care plan must be easily interpretable by any physician likely to
be a first responder to a medical emergency: A great challenge is how to reliably and clearly transmit through the
medical record nuanced discussions
of end-of-life care preferences so that
first responses to life-threatening conditions in patients with DNR orders
are consistently appropriate. Any care
plan must be easily interpretable to
guide emergent action until attending physicians are available to impart judgment over treatment choices.
For example, a care plan should
WWW.ARCHINTERNMED.COM
Model do-not-resuscitate supplemental document. BiPAP indicates bilevel positive airway pressure;
BP, blood pressure; CPAP, continuous positive airway pressure; DNI, do not intubate; DNR, do not
resuscitate; GI, gastrointestional; IV, intravenous; IVF, intravenous fluids.
CONCLUSIONS
Orders for partial resuscitation are
often confusing and deficient plans
for care. Care plans specifically guiding care for life-threatening conditions should be developed for all patients with DNR orders. These plans
should incorporate patients goals of
care, provide for patient refusal of
specific treatments, allow for physician discretion, reconcile requests for specific treatments with
care goals, and be readily interpretable. Successful implementation of
such care plans will require an
evolved paradigm of care in which
both patients and physicians are
more meaningfully empowered in
their partnering and in which the
health system allows patients, families, and professionals to recognize
and embrace timely deaths.
Accepted for publication December 17,
2002.
The author recognizes Gerald
Brody, MD, Anne Bantleon, RN, and
other members of the Winthrop
University Hospital Bioethics Committee for their collaboration in the
development of the model do-notresuscitate document.
Corresponding author and reprints: Jeffrey T. Berger, MD, 222 Station Plaza N, Suite 518, Mineola, NY
11501 (e mail: jberger@winthrop.org).
REFERENCES
1. NY Public Health Law, Article 29-B.
2. Council on Ethical and Judicial Affairs, American
Medical Association. Guidelines for the appropriate use of do-not-resuscitate orders. JAMA. 1991;
265:1868-1871.
3. American College of Physicians. Ethics manual,
fourth edition. Ann Intern Med. 1998;128:576594.
4. The Hastings Center. Guidelines on the Termination of Life-Sustaining Treatment and the Care of
the Dying. Bloomington: Indiana University Press;
1987.
5. American Heart Association in collaboration with
the International Liaison Committee. Guidelines
WWW.ARCHINTERNMED.COM
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
inson BE. Resuscitation decision making in the elderly: the value of outcome data. J Gen Intern Med.
1993;8:295-300.
Sayers GM, Schoefield I, Aziz M. An analysis of
CPR decision-making by elderly patients. J Med
Ethics. 1997;23:207-222.
Lipton HL. Do-not-resuscitate decisions in a community hospital: incidence, implications, and outcomes. JAMA. 1986;256:1164-1169.
La Puma J, Silverstein MD, Stocking CB, Roland
D, Siegler M. Life-sustaining treatment: a prospective study of patients with DNR orders in a
teaching hospital. Arch Intern Med. 1988;148:
2193-2198.
Casarett DJ, Stocking CB, Siegler M. Would physicians override a do-not-resuscitate order when
a cardiac arrest is iatrogenic? J Gen Intern Med.
1999;14:35-38.
Uhlman RF, Cassel CK, McDonald WJ. Some treatment-withholding implications of no code in an
academic hospital. Crit Care Med. 1984;12:879881.
Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 4th ed. New York, NY: Oxford University Press; 1994:196-202.
Shepardson LB, Youngner SJ, Speroff T, Rosenthal GE. Increased risk of death in patients with
do-not-resuscitate orders. Med Care. 1999;37:
727-737.
Evans AL, Brody BA. The do-not-resuscitate order in teaching hospitals. JAMA. 1985;253:22362239.
Hinkka H, Kosunen E, Lammi EK, Metsanoja R,
Puustelli A, Kellokumpu-Lehtinin P. Decision making in terminal care: a survey of Finnish doctors
decisions in end-of-life scenarios involving a terminal cancer and a terminal dementia patient. Palliat Med. 2002;16:195-204.
Roetzheim RG, Fox SA, Leake B. Physicianreported determinants of screening mammography in older women: the impact of physician and
practice characteristics. J Am Geriatr Soc. 1995;
43:1398-1402.
Franks P, Clancy CM. Physician gender bias in clinical decisionmaking: screening for cancer in primary care. Med Care. 1993;31:213-218.
Schneiderman LJ, Kaplan RM, Pearlman RA, Teetzel H. Do physicians own preferences for lifesustaining treatment influence their perceptions
of patients preferences? J Clin Ethics. 1993;4:
28-33.
Schneiderman LJ, Kaplan RM, Rosenberg E, Teetzel H. Do physicians own preferences for lifesustaining treatment influence their perceptions
of patients preferences? a second look. Camb Q
Healthc Ethics. 1997;6:131-137.
Heston TF, Lewis LM. Gender bias in the evaluation and management of acute nontraumatic chest
pain. Fam Pract Res J. 1992;12:383-389.
Tomlinson T, Brody H. Ethics and communication in do-not-resuscitate orders. N Engl J Med.
1988;318:43-46.
Evans AL, Brody BA. The do-not-resuscitate order in teaching hospitals. JAMA. 1985;253:22362239.
WWW.ARCHINTERNMED.COM