I. Just. Can't....

[OhioCCRN]

91yr old, end stage everything, family wants "everything" done despite multiple talks with MD's regarding what exactly is their expectation and how its not going to happen quite that way.. So when the pt coded, we got the family all close and personal with the code and all the rib breaking so that they could see that indeed we are doing "everything" .

Now they want to sue the hospital for battery and ABUSE because we broke the pts ribs during cpr....

I. Just. Can't......

[MunoRN, RN]

https://depts.washington.edu/bioethx/topics/dnr.html

This is an interesting site. Ethics-wise--at least according to this bioethicist--it is acceptable to DNR patients where CPR would be medically futile. However, if you read the cases, the ethicist doesn't have the balls to come right out and say, "Yes, DNR this patient." If an ethicist can't advocate for it in a hypothetical situation, I wonder how many doctors would do it in real life.

That actually seemed pretty straightforward, not all that wishy-washy:

When can CPR be withheld?

Virtually all hospitals have policies which describe circumstances under which CPR can be withheld. Two general situations arise which justify withholding CPR:

• when CPR is judged to be of no medical benefit (also known as "medical futility"; see below), and
  
• when the patient with intact decision making capacity (or when lacking such capacity, someone designated to make decisions for them) clearly indicates that he / she does not want CPR, should the need arise.
  

When is CPR "futile"?

CPR is "futile" when it offers the patient no clinical benefit. When CPR offers no benefit, you as a physician are ethically justified in withholding resuscitation. Clearly it is important to define what it means to "be of benefit." The distinction between merely providing measurable effects (e.g. normalizing the serum potassium) and providing benefits is helpful in this deliberation.

When is CPR not of benefit?

One approach to defining benefit examines the probability of an intervention leading to a desirable outcome. CPR has been prospectively evaluated in a wide variety of clinical situations. Knowledge of the probability of success with CPR could be used to determine its futility. For instance, CPR has been shown to be have a 0% probability of success in the following clinical circumstances:

• Septic shock
  
• Acute stroke
  
• Metastatic cancer
  
• Severe pneumonia
  

Keep in mind we're talking about just a low probability of success in some circumstances, we're talking a probability of zero, as in there has never been a reported case of successful resuscitation in some circumstances, despite a database of many thousands of patients.

[MunoRN, RN]

You didn't answer my question. At what point re: the patient's mental status is the decision made?

Take the example I used earlier in this thread about the stage 4 with mets everywhere, terminal, but alert and oriented. He was going to die from the cancer...he knew it, we knew it. No one knew if he would recover from a code, and many were skeptical that he would.

Would his case be one in which the docs would make him a DNR against his wishes?

Or are you talking about the unresponsive but stable patient who can't move, can't eat, can't swallow and keeps coming in for aspiration pneumonia because she can't handle her own secretions?

I'm just trying to get my mind around your hospital's policy.

I'm not sure what the patient's mental status necessarily has to do with it. We're not talking about taking away someone's decision making rights, we're talking about only having them chose between options that have at least some potential of benefit.

[MunoRN, RN]

Muno, how many cases are you personally aware of that a doctor has told the patient or family that the patient has been DNR'd due to medical futility, although the patient or family doesn't want it?

Our ICU typically has about 25 patients, there's probably one patient every few months who we declare medical futility despite family wishes for full code. I've never actually seen a family get upset about it, actually the opposite, every instance I've seen the family is relieved that they don't have carry the unfair burden declining an intervention that was for some reason offered despite it's lack of ability to provide any benefit to that patient.

Personally I think it's extremely cruel to offer patients and families a intervention that is futile given the particular patient's circumstances, forcing them to decline an intervention that has no potential benefit just to add some sort of extra level of guilt.

[Ruby Vee, BSN]

You didn't answer my question. At what point re: the patient's mental status is the decision made?

Take the example I used earlier in this thread about the stage 4 with mets everywhere, terminal, but alert and oriented. He was going to die from the cancer...he knew it, we knew it. No one knew if he would recover from a code, and many were skeptical that he would.

Would his case be one in which the docs would make him a DNR against his wishes?

Or are you talking about the unresponsive but stable patient who can't move, can't eat, can't swallow and keeps coming in for aspiration pneumonia because she can't handle her own secretions?

I'm just trying to get my mind around your hospital's policy.

That hospital has a sensible policy, as far as I'm concerned. Someone who has no hope of a meaningful recovery -- why not put them through a code that is essentially futile? That's a decision a doctor is fully qualified to make, and I wish more of them would.

[Susie2310]

Performing an intervention that has no indication for it's use in that patient is unethical.

The reason why we don't just let people chose to have open heart who don't need it is that we don't do things to people that serve no purpose, by definition medically futile CPR serves no purpose.

I refer you to MedlinePlus "Do Not Resuscitate Orders", in particular the paragraph "Making the decision," that explains that the patient can choose whether or not they want CPR to be done. Please tell me if a different law operates in your state, that does not give the patient this right.

[toomuchbaloney]

When I worked hospice I was very specific and graphic with patients and families about CPR.

I focused on the fact that what was killing them slowly would not be gone if we successfully resuscitated them, that the inevitable would simply be postponed and instead of dying at home they would die in the hospital attached to machines in the care of strangers.

I painted very very realistic pictures for them.

That really annoyed some family and patients. I had one catholic employer which directed me to be less graphic in my descriptions as they were upsetting. meh

[dudette10, MSN, RN]

Our ICU typically has about 25 patients, there's probably one patient every few months who we declare medical futility despite family wishes for full code. I've never actually seen a family get upset about it, actually the opposite, every instance I've seen the family is relieved that they don't have carry the unfair burden declining an intervention that was for some reason offered despite it's lack of ability to provide any benefit to that patient.

Personally I think it's extremely cruel to offer patients and families a intervention that is futile given the particular patient's circumstances, forcing them to decline an intervention that has no potential benefit just to add some sort of extra level of guilt.

So, the answer is none. You've never seen a doctor make a patient a DNR against the family's wishes. What you've seen is doctors talking to the families about the medical futility of a full code and the families agreeing with it.

[dudette10, MSN, RN]

That actually seemed pretty straightforward, not all that wishy-washy:

Oh, the main page is all full of absolutes. The cases to the right (Case 1, Case 2, Case 3) is where it gets wishy-washy.

Keep in mind we're talking about just a low probability of success in some circumstances, we're talking a probability of zero, as in there has never been a reported case of successful resuscitation in some circumstances, despite a database of many thousands of patients.

Metastatic cancer is on that list. I just reported one in this thread.

Before someone accuses me of being a clueless champion of "doing everything possible in every circumstance," I'm only advocating against what seemed to be the policy of your hospital in your first post on the subject, i.e. doctors making a patient DNR against the expressed wishes of the family, even after talking in detail with the family.

[dudette10, MSN, RN]

I'm not sure what the patient's mental status necessarily has to do with it. We're not talking about taking away someone's decision making rights, we're talking about only having them chose between options that have at least some potential of benefit.

It has a lot to do with it, if you are able to put yourself in a place where you are terminal, dying, you want to be a full code, and the doctor is saying no. I can imagine that it would be much easier to tell families that a DNR will be made against their wishes, when their loved one is unresponsive vs telling an alert and oriented, but dying, patient that a DNR will be made, regardless of his/her wishes.

Unresponsiveness is not the criteria for declaring medical futility; the probability of successful resuscitation is. So, the scenarios above are both equally possible. That means, by your definition of medical futility, that it would be UNETHICAL to code an alert and oriented patient with metastatic cancer near the end of life if he so wishes. Am I interpreting your stance correctly?

Thank goodness that ethics is much more complicated than a simple set of rules, because I feel that the ethical concepts of autonomy and beneficence (emotionally, spiritually) takes precedence over the ethics of medical futility in some cases.

[dudette10, MSN, RN]

These observations seem to lead to the following, somewhat disquieting conclusion. If a consent process were to be applicable to the withholding of treatments that might be in a patient’s best interests to receive, and the patient’s subjective input were required to determine what was in his or her best interests, then consent might be required to withhold any therapy that the patient defined as being indicated. I say disquieting because such a conclusion appears to legitimise the requests of patients for treatment that may appear harmful or bizarre to the treating doctor.

Tomlinson and Brody address this concern by arguing that the presence of value judgments in futility assessments does not negate a doctor’s right to make such assessments nor to use them as a basis for withholding treatment that he or she believes is against a patient’s interests.¹⁹ They argue—for example, that a cardiac surgeon cannot be obliged to perform bypass surgery on a patient with angina, whom the surgeon believes has a high chance of dying on the operating table, even if that patient competently insists that he or she wishes to take the risk. To honour the request, they continue, would entail the doctor breaching his or her duty to act in the patient’s best interests as the latter requires offering treatment likely to deliver a net benefit to the patient.

I would suggest, however, that this conclusion simply amounts to assigning primacy to the physician’s value judgment (that a particular course of action would result in harms outweighing benefits) over the patient’s value judgment (that in fact the benefits of the treatment outweigh the harms). I would dispute the validity of always according the physician’s values such primacy.

This is an excerpt from one of the links. Coincidentally, it uses the exact same analogy about heart surgery that you used previously in this thread, Muno. The conclusion that author comes to, however, is that the "primacy of physician values", i.e. that a doctor is best suited to make treatment decisions in the best interest of the patient regardless of the patient's wishes, does not and SHOULD NOT apply in all circumstances.

Later in the article:

We seem to have arrived at a position that finds few reasons to justify individual physician primacy in judgments over whether treatments deemed futile by the physician can be legitimately withheld. This position is grounded in the idea that disputes over whether a treatment is warranted are in part disputes about the relative values of the individuals involved. Absolute physician primacy appears to entail placing a higher priority on the physician’s values than on those of the patient. In many cases, to do so appears morally indefensible because it makes an erroneous epistemological claim that medical expertise leads to a similar expertise in assessing the merit of individual values.

ETA: I want to say, Muno, that I LOVE this discussion with you. We might not agree, but it is a very stimulating conversation for me. Thank you, sincerely, for participating. And, we're not done yet.... :)

[toomuchbaloney]

It has been an extremely interesting conversation.

I am not terribly familiar with physicians who impose DNR sensibilities upon patients.

I am more familiar with physicians who seem to view death as some sort of failure on their part which is to be fought and avoided at ALL costs. It sometimes seemed that they were happy to do CPR on futile cases so that they could later say..."we did everything we could"...

Hospice work really opened my eyes to the level of denial that is practiced amongst MDs when it comes to the deaths of their patients.

[duskyjewel]

Hospice work really opened my eyes to the level of denial that is practiced amongst MDs when it comes to the deaths of their patients.

I have a glimmer of hope to offer. Today I met the THIRD young pre-med student volunteering in our hospice inpatient units. Maybe the next generation of doctors will be a little better. I told him how awesome I think it is that he's chosen to be there. :)