Wednesday, April 1, 2009

DNR Best Practices?

Rosemary Flanigan
April 1, 2009

Remember my telling you about the patient with terminal renal cell carcinoma who is incompetent, has had a guardian appointed, and the team of 7 physicians caring for him thought it appropriate to have a Do Not Resuscitate Order.

I heard this morning that he has it!!! The ethics committee, after discussing “at length the various legal, moral, and ethical reasons both for and against instituting a DNR when the patient no longer possesses the decisional capacity to decide for himself,” concluded that the 2 physician specialists would co-sign the DNR and that the team leader would write a treatment plan to be shared with unit staff regarding what measures would or would not be taken in the event of a medical emergency.

Personally, I think that was a defensible outcome; I assume that the guardian agreed. Amazingly, during the course of all this, they were able to find family members whom he had not seen in 5 years and who were satisfied with the DNR and the treatment plan.

My peek into the future of healthcare reform tells me that there will be more DNR orders initiated and encouraged by physicians along with patient/family proposals. What my “peek” doesn’t tell me if whether or not there will be some “best practice” guidelines that will simply mandate a DNR order, regardless of physician OR patient OR family concurrence.

What do you think?

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Blogger Practical Bioethics said...

Comparative effectiveness in the near future will most likely require it. Very few frail elderly patients or those in advanced disease states can benefit from CPR.

For this population, the intervention usually does more harm than good - based on medical outcomes. Procedures that cannot benefit patients should not be our default intervention.

Vice President, Aging and End of Life
Center for Practical Bioethics
816.979.1353 (direct)

Wednesday, April 01, 2009  
Blogger Practical Bioethics said...

As many of you have heard me say, I am very interested in the conversations prompted by Rosemary, but most often, I "sit on the sidelines".

However, this conversation compels me to "get off the bench". As John Carney points out in his email, the data (and the data for a very LONG TIME -- bless Leslie Blackhall, et. al.) has indicated that CPR provides minimal benefit to hospitalized patients and may, in fact, lead to significant long-term harm.)

Our former board member and respected physician/ethicist, Bill Bartholome, responded to the work of Blackhall and others by writing an article for the Annals of Internal Medicine in which he suggested that 'the only people who should be subjected to CPR in a hospital were guests or house staff."

I know and respect Andy Billings (and his wife, Susan Block -- what a couple!); I wish, however, that Andy had titled his presentation, "Physicians Without a Touchstone: Non-maleficence, a Forgotten Principle"

Given the data, when is it that we will demand that the current "resuscitate unless the patient or surrogate agrees to a DNR order and signs in blood so that physicians have absolute legal immunity (or believe that they do)" policy is over-turned in exchange for a policy that, upon admission, a physician, based on his or her best clinical judgement must write an order regarding CPR, DNR, DNAR or whatever acronym we wish to cloak this argument is required?

(Much like the physician must write prescription orders which may be far more "lethal" with regard to the patient's ultimate outcome.)

I have publicly been referred to as an "autonomy freak". I love the concept of autonomy, but I have great respect for the practice of medicine and tremendous regard for the integrity of physicians.

Enough is enough!

In my opinion, it is time for the medical professions to resolve this issue.

I feel certain that I have made some of our nearest and dearest angry, but it is late, and I am tired, and this is what I have thought for a long time.

Myra Christopher
Center for Practical Bioethics

Thursday, April 02, 2009  
Blogger Practical Bioethics said...

Research shows that DNRs are often interpreted by clinicians as Do Not Repond. It is one of the reasons that POLST (Physician Orders for Life Sustaining Treatment) initiatives have grown from just a handful in 2004 to more than 2 dozen states in 2009.

POLST documents, while targeted specifically to those in advanced disease states and frail elderly, provide a broader and more comprehensive set of physician order sets matching patient preferences to address end of life treatment directives (e.g., ICU admission, hydration and nutrition, antibiotics, surgery).

Research also shows that even this group of patients for whom DNRs (no CPR attempt) are warranted, more than 2/3 want other measures of life sustaining treatments.

John Carney

Friday, April 03, 2009  
Blogger Practical Bioethics said...

My question is, “Given all we know, why do we not change institutional policy and practice?”

Myra Christopher

Friday, April 03, 2009  
Anonymous viagra online pharmacy said...

I think that it is so important to know because the Alternative naming and abbreviations for this order are used depending on the geographic region. DNR is a common abbreviation in the United States and the United Kingdom.
Thanks for sharing it is so interesting!22dd

Tuesday, March 08, 2011  

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