I. Just. Can't....

duskyjewel · Sep 7, 2014

I was hoping that was sarcastic.

PMFB-RN, RN · Sep 7, 2014

I was hoping that was sarcastic.

Of course. It's why I put the :) behind it. Sorry if I didn't make it clear I was being cynical and sarcastic.

Susie2310 · Sep 7, 2014

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:
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.

My internet search of this subject brought up over 232,000 matches. I have read some of them. There appears to be no consensus among physicians about what is the "right" action in these kinds of situations, when the patient (or family) chooses to be resuscitated and the physician believes resuscitation should not take place. Legal opinions differ, and some arguments are made for patients choices to be upheld even in cases where medical care could be considered futile (and even the use of the words "medically futile" is disputed by some). I will hold to my original position.

LadyFree28, BSN, LPN, RN · Sep 7, 2014

Of course. It's why I put the :) behind it. Sorry if I didn't make it clear I was being cynical and sarcastic.

I got it. :yes:

MunoRN, RN · Sep 7, 2014

My internet search of this subject brought up over 232,000 matches. I have read some of them. There appears to be no consensus among physicians about what is the "right" action in these kinds of situations, when the patient (or family) chooses to be resuscitated and the physician believes resuscitation should not take place. Legal opinions differ, and some arguments are made for patients choices to be upheld even in cases where medical care could be considered futile (and even the use of the words "medically futile" is disputed by some). I will hold to my original position.

There are various consensus statements to refer to, all agree the same basic premise; agreement between the Physican and patient/family should be sought through various means but if those fail then in the end the Physician may refuse to provide interventions which have no potential for benefit. Even the one's I might guess would be exceptions to the consensus take that same stance. Here's a list of the various consensus/position statements: Palliative Care Ethics, Position Statements

I think what you are referring to is whether we should broaden what qualifies as futile care, which is true there is some debate about, but in terms of care with absolutely no potential for benefit there is no lack of consensus.

If you support the right to medically futile codes maybe you can share how you think that should be done. The current method is the 'slow code'/'show code'/'light blue code'. What amount of time would be appropriate to pretend to code someone? How do we know when to call it?

ixchel · Sep 8, 2014

Ya but they can be good practice for the residents and interns:)

There were a few over one of my clinicals that were coded for ages and ages as practice. One they brought back, "by accident" you could say. Lasted 2 days in ICU before finally coding and not coming back. I hope that MD learned his lesson.