Sunday, May 11, 2014

Unilateral Do-Not-Attempt Resuscitation Orders at the Massachusetts General Hospital

The American Thoracic Society International Conference begins this week in San Diego.  There are a number of sessions and posters related to end-of-life ethics.  This one seemed particularly interesting.

Unilateral Do-Not-Attempt Resuscitation Orders In A Large Academic Hospital
A. Courtwright, MD, PhD
S. Brackett, RN, BS, CCRN
E. Robinson, RN, PhD

Unilateral Do-Not-Resuscitate (DNR) orders are a specific type of medical futility decision in which clinicians withhold advanced cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest despite objections of patients or their surrogates.

There is little information on how often and to whom unilateral DNR orders are applied. The ethics committee at Massachusetts General Hospital has had a unilateral DNR policy since 2006. We investigated the incidence, sociodemographic and clinical predictors, and outcomes of patients with unilateral DNR orders.

We reviewed all ethics committee consults that involved disagreement between health care providers and patients/surrogates over intensity of treatment, including DNR status. We used bivariate and multivariate statistics to compare sociodemographic and clinic data from cases in which unilateral DNR was and was not recommended. We recorded whether this recommendation was actually followed and patient disposition following consultation.

There were 147 cases of conflict over intensity of treatment and DNR status. Of these, the ethics committee recommended unilateral DNR 35% of the time and this recommendation was followed in 83% of cases. 

Neither age (70±3.9 years versus 73±2.5 years, p=0.43) nor female sex (38% versus 50%, p=0.63) was associated with unilateral DNR recommendation. Patients for whom unilateral DNR was recommended were more likely to be non-white (48% versus 26%, p=0.05). Measures of functional status prior to admission, including number of medical comorbidities (3.8±0.28 versus 3.2±0.22, p=0.08) or full or partial dependence in activities of daily living (62% versus 50%, p=0.36), were not associated with unilateral DNR recommendation. Patients for whom unilateral DNR was recommended were more likely to have conditions judged to be endstage rather than potentially reversible (62% versus 41%, p=0.05). Patients for whom unilateral DNR was actually ordered were more likely to die during their hospitalization (79% versus 48%, p=0.01).

Patient age, gender, and functional status prior to admission are not associated with an ethics committee’s decision to recommend a unilateral DNR order. Non-white patients and patients judged to have end stage conditions are more likely to have a unilateral DNR order recommended. Patients who are actually made DNR unilaterally are more likely to die in the hospital.


Carol Eblen said...

it appears that this study included only those patients who consulted with the Ethics Committee about the DNR code status because they disagreed with the the DNR Code Status.
Therefore, all of these patients were informed by the hospital that there was a DNR in their charts?
But, did the study look at the DNR statistics of patients who cidn't object to the unilateral DNR Code Status when informed that it was in their chart?

What does the 35% agreement to unilateral DNR by the Ethics Committee tell us about the difficulty of proving "medical futility?"

B.Mukarji said...

Unilateral DNARs disrespect democracy

As a “non-white” caregiver and stakeholder , I believe , that in a democracy,there is no justification -medical or ethical - for denying any patient access to non-extraordinary treatments of resuscitation , especially when the choice reflects their well informed voluntary end of life (EOL) wish, made in consultation with physicians as part of advance care planning.

It’s not so much an obligation to their profession , as a respect for the due process, a fundamental principle of democracy. A physician can not tell patients they respect their autonomy , then refuse them the critical last choice to attempt resuscitation overriding their objections. Requests for a chance to attempt resuscitation often originate as a last act of dignity – to end life in one‘s own terms - than any unreasonable expectations of cure.

The end of life choices of non-white patients are based on their own values about life and “natural” death, family and futility, which may not derive from the Hippocratic tradition or the Georgetown Principlism , the framework of the prevailing norms of white medical ethics. The practice of unilateral DNAR, DNR or even AND (Allow Natural Death) typically ignore the rights of minorities to practice their own faith in EOL Choices,

adrian8712 said...

I agree that the study is skewed towards the patients which do have a DNR code in their charts.

However it can also expand to whether general patients without terminal illnesses would agree to Unilateral DNR Orders on their charts in their instance.

Something to think about.