March 1991 XII/7
CPR AND DNR REVISITED
About sixty years ago when a person's heart stopped beating and the lungs stopped breathing, the person was declared dead. But through a series of experiments in the 1940's, it was discovered that the heart could be resuscitated through both drugs and electrical stimulation. In 1960, research demonstrated that circulation also could be restored by external cardiac message. At first, emergency cardiac resuscitation was used mainly in recovery rooms at hospitals and by persons called upon to give emergency medical care, such as life guards, police, firefighters and ambulance personnel. Later, in the 1970's and 80's, hospitals and many long-term care centers developed policies which mandated resuscitation efforts (CPR) for all patients who suffered cardiac arrest. (1) Experience quickly demonstrated however, that not all persons suffering cardiac arrest in health care facilities would benefit from CPR. In an effort to designate in advance those patients who would not benefit from CPR, or who did not wish this form of therapy, Do Not Resuscitate (DNR) orders were developed in many health care facilities. In spite of the frequent use of CPR and the frequent issuance of DNR orders, there are several ethical issues which continue to occur in hospitals and long-term care facilities in regard to cardiopulmonary resuscitation. In this essay we shall consider some of these issues.
Principles
Cardiac arrest occurs at some point in the dying process of every person whatever the underlying cause of death. Hence, the decision whether or not to attempt resuscitation is potentially relevant for all patients. In theory, CPR for cardiac arrest is a multi-step process. Usually it includes chest compression, administration of various medications, electrical shocks to restart the heart, placement of a breathing tube (intubation), and placement on a breathing machine (ventilator). In practice however, the medical team conducting CPR will not wait to see if the initial steps are successful before beginning the more aggressive procedures. Thus CPR is usually envisioned as a single therapy aimed at restoring cardiopulmonary function. As such, it may be evaluated ethically as are other life prolonging therapies. The essential ethical question for its use being: Will it benefit the overall well-being of the patient? Patient well-being is discerned by considering more than the physiological function of the patient. Keeping the patient alive is not the ultimate criterion for ethical medical care. The social and creative function of the patient must also be considered. Specifically, overall patient benefit may be discerned by asking two questions: Does the life prolonging therapy impose a grave burden upon the patient? and is the therapy ineffective (2) insofar as the overall well-being of the patient is concerned? If either of these questions is answered affirmatively, then there is no ethical imperative to utilize the therapy in question.
Discussion
While the general principles for use of CPR are not difficult to understand, over the years the application of these principles has occasioned several ethical questions. Who should be considered as an apt patient for CPR? For whom should DNR orders be written. Studies demonstrate that severely debilitated patients, for example, those suffering from cancer or sepsis seldom recover cardiopulmonary function after CPR. Even if severely debilitated patients were resuscitated, some patients survived in a persistent vegetative state. Many of those who did recover some degree of cognitive-affective function died of other causes before leaving the hospital. In order to withhold CPR from a patient through a DNR order, it must be determined in advance that attempts at resuscitation would either impose a grave burden upon the patient or be ineffective therapy insofar as the overall well-being of the patient is concerned. When would CPR be considered a grave burden in relation to the benefit it might bring? in this regard, several people mention the broken bones and bruises that may result from the various steps in the resuscitative process. While some physical injury may result from CPR, in most cases it seems withholding it on the grounds of physical burden would not be reasonable if weighed against the benefit of prolonged life. Perhaps the patient with severe osteoporosis would suffer serious injury from CPR, which would not be offset by the benefits, but it is not immediately evident that others would experience the same burden. When assessing grave burden, other sources of burden besides physiological suffering should be considered. For example, the economic, social and spiritual effects of the therapy must also be evaluated. The President's Commission on Ethics in Medicine opined that resuscitation efforts usually provide benefits that justify their costs. (3) in itself CPR would not seem to impose a social or spiritual burden upon the patient or the family, unless it could be foreseen that resuscitation would result in a respirator dependent condition. If this were predicted, it might be considered that living in this condition would be too burdensome and thus request for a DNR order would be in order.
Would CPR ever be ineffective therapy insofar as a patients well-being is concerned? Would CPR be effective therapy for a person in a persistent vegetative state, or for a person in a seriously demented condition? Would CPR benefit patients with end stage diseases, such as cancer of the lungs or pancreas, if it would prolong their lives for only a few days? When a determination is made that CPR would be ineffective, it is an admission that this therapy is not conducive to the overall well-being of the patient, either because it is unlikely to benefit the patient (and this should be demonstrated through clinical research) or that it will not benefit the patient even if it does work. Declaring a therapy to be ineffective is an admission that science and medicine are unable to benefit the patient. Declaring a therapy to be ineffective is not the same as saying the therapy will not prolong life. Who decides whether CPR will be beneficial for the overall well-being of the patient? Who is the person responsible for determining that a DNR order will be issued because CPR will impose a grave burden or be ineffective? For many years, this decision was considered to be the prerogative of the competent patient, or of the proxy, if the patient were incapable of making the health care decisions. But as evidence proving the ineffectiveness of CPR for some patients becomes more extensive, it was suggested that the attending physician could make this decision unilaterally and not communicate it to the patient or proxy. (4) Thus, the attending physician could determine that CPR was not an apt therapy for certain patients, just as an attending physician can determine that laetrile is not fitting therapy for reversing the growth of cancer cells. In certain circumstances it seems that physicians should make a decision that CPR is not an effective therapy. This is well within the ambit of ethical medicine. But because CPR is considered a standard therapy, this decision should be communicated to the patient or proxy. To write a DNR without communicating this decision to patients or their proxies would seem to violate their moral right to informed consent.
In the everyday practice, the Slow Code, or Hollywood Code is sometimes in evidence. This practice is characterized by "going through the motions", a decision having been made in advance by care givers that the patient will not benefit from CPR, but no one having had the courage to write the DNR order. Similar to this approach is the predetermined decision to utilize only part of the CPR procedures and to withhold electrical shock and intubation if the less aggressive steps do not restore cardiopulmonary function. The many steps of CPR have one goal: to restore cardiopulmonary function. Half hearted efforts to achieve this goal would seem to be unethical. If the therapy is judged to be effective, it should be utilized in such a way that will ensure its success. Stopping CPR halfway through the process is simply another manner of going through the motions.
Conclusion
Does writing a DNR order necessarily imply that the patient should have all life prolonging therapy withdrawn? in general, the answer to this question is no. Each life prolonging therapy should be judged upon its own merits. But the medical indications which would justify withholding CPR may discourage the use of other therapies. Hence, if a DNR is written for an unconscious patient with end stage disease, it seems an evaluation of all life prolonging therapy is in order.
Kevin O'Rourke, OP
Footnotes 1) President's Commission on Ethics in Medicine & Behavioral Research; Deciding to Forego Life Sustaining Treatment, Government Printing Office, 1983, 231ff.
2) Ineffective therapy is often called useless or futile therapy, cf. Schneidernan, Jecker, and Jonsen; "Medical Futility: its Meaning and Ethical implications," Annals of internal Medicine 112:12, 949-954.
3) loc.cit.
4) Murphy, "Do Not Resuscitate Orders: Time for Reappraisal," JAMA 260:14 (October 14, 1988) 209ff.
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