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....
Specializes in NICU, PICU, Transport, L&D, Hospice.
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. :)
One of my recent hospice employers collaborated with a local university to provide clinical rotations for medical and nursing students. It was a wonderful thing to introduce these budding professionals to the specialness that is hospice care.
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.
Patients in every state have the right to chose not have CPR done, even if it an offered treatment. I'm not sure where you got that there was any explanation of state laws in this article.
There is some variation from state to state in the laws surrounding futile treatment. There is no state were declaring medical futility and withholding treatment is legally banned. In most states it is a civil matter not addressed by law either way, cases are judged by expert consensus and precedent. There are some states, such as Texas, which have created a 'safe harbor' situation for Physicians which limits their civil suit liability in exchange for certain requirements they must follow when declaring medical futility and withholding treatment despite patient/family objections. There are other states that also limit the civil liability of Physicians/facilities but with few restrictions, typically the only absolute requirement is that Physicians inform the patient/family that certain treatments are being withheld due to medical futility.
There are very good and in-depth articles on what's typically called 'unilateral DNR' although most of what I can find requires log-ins, here's one with a pretty comprehensive abstract:
There is an emerging consensus today that specific case profiles exist in which in-hospital cardiopulmonary resuscitation (CPR) would be futile care and in which a do not resuscitate (DNR) order is medically appropriate. The physician's affirmative decision to perform CPR usually is made without involvement of the patient or the patient's family. On the other hand, DNR orders seldom are issued without consent of the patient or the patient's family, even though the patient is not likely to survive CPR. The concept of patient autonomy, however, does not extend to the patient and/or family a legal, ethical, or social right to futile care, particularly CPR that is futile. As such, the treating physician is not required to obtain the patient's and/or family's informed consent prior to issuing a DNR order, but has the unilateral authority to enter such an order.
Resuscitation has been around long enough that we have reliable data on who can and who won't benefit from it. There are some circumstance where resuscitation is actually very likely to be successful, there are also other circumstances where the potential for success is not only low, but 0%, yet you seem to feel we should still provide a treatment where it's absolutely clear it's of no benefit. How is it ethical to provide a treatment that carries no potential for benefit?
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.
I was referring to occasions where the doctor talking to the families about the medical futility of a code doesn't resolve the situation and medical futility must be declared, which is relatively rare and there's maybe one case every few months in my ICU.
Patients in every state have the right to chose not have CPR done, even if it an offered treatment. I'm not sure where you got that there was any explanation of state laws in this article.
There is some variation from state to state in the laws surrounding futile treatment. There is no state were declaring medical futility and withholding treatment is legally banned. In most states it is a civil matter not addressed by law either way, cases are judged by expert consensus and precedent. There are some states, such as Texas, which have created a 'safe harbor' situation for Physicians which limits their civil suit liability in exchange for certain requirements they must follow when declaring medical futility and withholding treatment despite patient/family objections. There are other states that also limit the civil liability of Physicians/facilities but with few restrictions, typically the only absolute requirement is that Physicians inform the patient/family that certain treatments are being withheld due to medical futility.
There are very good and in-depth articles on what's typically called 'unilateral DNR' although most of what I can find requires log-ins, here's one with a pretty comprehensive abstract:
Resuscitation has been around long enough that we have reliable data on who can and who won't benefit from it. There are some circumstance where resuscitation is actually very likely to be successful, there are also other circumstances where the potential for success is not only low, but 0%, yet you seem to feel we should still provide a treatment where it's absolutely clear it's of no benefit. How is it ethical to provide a treatment that carries no potential for benefit?
My point in referring you to the Do Not Resuscitate Order information on MedlinePlus was to illustrate that the patient has the right to choose whether or not to be resuscitated.
People are entitled to make their own choices about whether they wish to be resuscitated, as the MedlinePlus information illustrates, even if they may not survive the procedures, or may experience reduced quality of life.
Your ethical position is yours. Medical futility or not, patients and families have their own values and beliefs, and are entitled both morally and legally to make their own choices about resuscitation.
As I said in my earlier post, I will not hesitate to contact my state medical board and/or a lawyer if necessary in regard to the care my older family members are receiving.
Resuscitation is a medical intervention, and just like all other medical interventions the patient cannot simply chose an intervention that the Physician doesn't agree would be of any benefit. For instance, a person with no indications for open heart surgery couldn't go to a surgeon and say they want the surgery and the surgeon must provide it for them, it's up to the surgeon to determine if that's an intervention that's appropriate to offer the patient.
I get what you're saying, but boy is that a slippery slope. Who decides this and where are the lines drawn? I have very mixed feelings.
There is no state were declaring medical futility and withholding treatment is legally banned.
The concept of patient autonomy, however, does not extend to the patient and/or family a legal, ethical, or social right to futile care, particularly CPR that is futile. As such, the treating physician is not required to obtain the patient's and/or family's informed consent prior to issuing a DNR order, but has the unilateral authority to enter such an order.
Yes, there is. It's either New Jersey or New York that requires patient or family consent to a DNR. It is by statute, not regulation nor case law.
With respect to the bolded type, I need to read the whole link, but how does the concept of physician autonomy extend to the physician's legal, ethical and social right to withhold CPR? In some ethicists' views, it doesn't. As my previous posts show, physician values do not supercede the patient's values in life-or-death interventional circumstances.
My point in referring you to the Do Not Resuscitate Order information on MedlinePlus was to illustrate that the patient has the right to choose whether or not to be resuscitated.
People are entitled to make their own choices about whether they wish to be resuscitated, as the MedlinePlus information illustrates, even if they may not survive the procedures, or may experience reduced quality of life.
Your ethical position is yours. Medical futility or not, patients and families have their own values and beliefs, and are entitled both morally and legally to make their own choices about resuscitation.
As I said in my earlier post, I will not hesitate to contact my state medical board and/or a lawyer if necessary in regard to the care my older family members are receiving.
I don't actually see anything in the Medline article that states a Physician is legally barred from declaring medical futility, I think you may be misinterpreting some of the statements. There are sources however that are more clear, such as:
Physicians are not obligated, either from a legal or ethical standpoint, to provide care that falls outside of the standard of care.11 This includes medically futile treatments.
There are also specific state laws that spell out the requirements for a unilateral DNR, none of which completely prohibit it being done, altlhough in some states a court order is needed. There are also many cases where medical futility declarations have been contested but upheld, which would seem to contradict your questionable interpretation of the medline article. Can you provide anything that actually says it's illegal to declare medical futility?
The bigger question however is why you would want CPR to be performed when it's futile. I agree with your assertion that patients should be allowed to chose interventions that are not guaranteed to be successful, but that's not what we're talking about, we're talking about patients with absolutely no chance of recovery as a result of CPR.
I think it helps to understand what the purpose of CPR is. It's purpose is to buy time to allow a reversible cause to be treated, such as in an MI where CPR provides continued perfusion of the brain until the patient's own perfusion can be restored.
To use an example which was the first patient I had where a medically futile DNR was declared, the patient's annular ring of their aortic valve was necrotic and only a small portion of it remained holding the aortic valve. We knew from serial echos the rate at which the aortic valve was coming lose and that in the next few days it would completely break free and that CPR would have absolutely no chance of altering the course. Surgery was not an option and so there was no process left to reverse. What I saw coming for that patient was what I had seen in previous facilities which is what's called the "slow code"; an unenthusiastic process of going through the motions, where those performing the code know full well it has no potential for benefit and as a result just try and be as minimally abusive as possible to a patient as they die.
The general rule in coding a patient is that you continue until all reversible causes have been addressed, if the patient continues to be in arrest/pulseless then the code is stopped. In a medically futile situation such as this one where a futile DNR is declared, the same premise is followed, you only code the patient so long as there are reversible causes to address, which for some patients the underlying cause is already known to be not reversible before the code even starts.
Yes, there is. It's either New Jersey or New York that requires patient or family consent to a DNR. It is by statute, not regulation nor case law.
I think you're thinking of the NY law which is one of the more restrictive state laws governing medical futility declarations, although it doesn't actually go so far as to completely outlaw the practice, it requires that a court order be obtained to override the patient/family wishes. Although even that requirement hasn't been completely clear since the law itself seems to require a court order, but the regulations for the law allow for a unilateral withdrawal of treatment in the case of medical futility, the discrepancy has yet to be clarified in court.
It gives a perspective on the rationale behind the practice.
With respect to the bolded type, I need to read the whole link, but how does the concept of physician autonomy extend to the physician's legal, ethical and social right to withhold CPR? In some ethicists' views, it doesn't. As my previous posts show, physician values do not supercede the patient's values in life-or-death interventional circumstances.
The right of Physicians to not be required to take part in purely harmful treatments has been around since Hippocrates. I agree it gets much more complicated when we're talking about "life-or-death" issues where we're comparing benefits to risks, but that's not what we're talking about, we're talking about "Death-or-death" situations.
The less long-winded explanation: The generally accepted standard for ending CPR is when the possibility for reversing the cause of the arrest no longer exists; when all potential for reversing the arrest has been exhausted.
In some patients the cause of an impending arrest is well understood prior to the actual arrest, and if that cause is not reversible then the basis for ending a code exists before it even starts.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
In some patients the cause of an impending arrest is well understood prior to the actual arrest, and if that cause is not reversible then the basis for ending a code exists before it even starts.
Ya but they can be good practice for the residents and interns:)
SCBlueICU
13 Posts
Lack of understanding of critical care medicine and what it can and can't do are huge across the USA. Big problem.