Mrs. C was admitted to the ICU after suffering an acute stroke. Owing to respiratory distress, she is on a ventilator. A widow with no advance directive, Mrs. C's son Bob is her most qualified surrogate decision maker. Dr. D feels that the end is near, although not imminent, and approaches Bob to discuss a do-not-resuscitate (DNR) order. We can try to resuscitate your mother if her heart stops," says Dr. D, "Patients over seventy, like your mother, will probably not benefit from cardiopulmonary resuscitation - especially if they have respiratory distress and acute stroke with neurologic deficit. If we did CPR, your mother probably wouldn't survive. If she did she might end up permanently on the vent. We do not want to cause her any more pain or suffering. Do you want CPR?"
At first Bob wants everything done, but by the end of the discussion he agrees to a DNR order. Dr. D writes the order and informs the ICU staff. Bob returns to the waiting area, feeling as if he's condemned his mother to death. The doctor, on the other hand, feels good. He doesn't think that CPR is warranted for this patient due to poor outcome measurements, he has the DNR order, and he made sure that the staff knew about it. Both men are concerned about Mrs. C - why do they have such different perceptions of their conversation? How can DNR discussions be placed in an ethically sound context that encourages appropriate care?
The decision to withhold CPR can be very hard for patients, families, and health care providers. Ideally, a physician should discuss a patient's preferences for end-of-life care well in advance of a life-threatening crisis. The primary reason for discussing DNR and other end-of-life treatment options is not to reach agreement on a specific treatment, but to help patients and families understand care options and the limitations of medicine. Placing DNR in the context of the overall treatment goals helps staff, family, and patients face this difficult decision.
A DNR discussion should take place whenever the patient or physician feels that CPR would not be beneficial, after a realistic evaluation of intervention goals. In discussing DNR with patients or surrogates, a physician should consider two tips:
1) Don't focus the discussion on code status alone. At this stage, the overall plan for the patient's care is the issue, not just the code status. If the provider's interest seems to be "getting the DNR," many families react as if the physician has suggested that they abandon their loved one. Many equate technological aggressiveness, such as CPR, with caring. By agreeing to a DNR order, family members often feel that they are authorizing the death of their loved one. By emphasizing that care will continue, doctors may relieve families of this feeling.
After explaining the risks and benefits of CPR, Dr. D might say something like, "Your mother's condition is quite serious. All of the doctors taking care of her have discussed her care, and we all agree. We have considered the consequences of cardiopulmonary resuscitation. It is time to think about a care plan that aggressively supports her comfort and dignity. Here's what I think we should do. I will write an order not to try resuscitation if her heartbeat or breathing should stop. At this point CPR would do only harm and no good. I will order only medicines that help manage pain and symptoms, and stop things that are no longer appropriate. We'll reevaluate her condition regularly and adjust her care. I will arrange for you to be with her as much as you would like." In this way, the issue of DNR is placed in terms of overall patient care or treatment goals.
2) The issue is not what the surrogate wants, but what the patient would want, given the physician's recommendation. A DNR conversation can be a good time to review the surrogate's role ("This is your mother's condition. These are my recommendations. Since we do not have a written directive from her, your role is to give voice to her voice. If your mother could talk to us about all this, what do you think she would say? What would she want done in such a situation?") This is a way of sharing the emotional burden of the DNR decision. It's not only the son's decision ("Do you want CPR?") or the doctor's, but a shared decision to provide the best care possible for this patient.
It may be useful, therefore, to discuss DNR in a patient care conference, during which participants identify: (1) achievable medical goals; (2) achievable patient goals (what outcomes the patient would want, if able to express them); (3) a care plan, with time frames, clinical indicators of patient improvement or deterioration, and identification of caregivers and their roles; and (4) a plan for regular re-evaluations. The health care team should emphasize that aggressive efforts to manage the patient's discomfort and symptoms will be provided, and that the patient's function and dignity will be maintained to the extent possible. The physician should explain the planned treatment course from this point on, and offer to arrange for psychosocial and spiritual care. In these ways, by seeking achievable medical goals as much as possible in light of patient values, the focus is on the care and treatment to be provided, not on what is withheld.
