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Zhe Wong GH, Kiat Yap PL. Ageism and Dementia-ism in Health Care: A Proposed Framework to Guide Treatment Decisions in Frail Older Persons. J Am Med Dir Assoc 2024; 25:105015. [PMID: 38750656 DOI: 10.1016/j.jamda.2024.105015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 03/28/2024] [Accepted: 03/28/2024] [Indexed: 05/27/2024]
Abstract
Global population ageing underscores the imperative of ageism and dementia-ism in the heath care setting as there is both anecdotal and published evidence that older persons are liable to receive less than optimum evidence-based treatments on account of their age and apparent frailty. This article explores the reasons for this phenomenon and limitations of current approaches of clinical decision making. We propose a framework to guide decision making to optimize care, with a paradigm shift in redefining a default toward clinical practice guideline-recommended treatments, guided by evidence-based medicine within an ethical means-end proportionality framework, and regularly reviewed advance care plans and goals of care conversations to secure the best interests of older persons.
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Cobert J, Chapman A, Smith A. Vasopressin and Methylprednisolone vs Placebo and Return of Spontaneous Circulation in Patients With In-Hospital Cardiac Arrest. JAMA 2022; 327:486. [PMID: 35103772 DOI: 10.1001/jama.2021.23051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Julien Cobert
- Department of Anesthesiology, San Francisco VA Health Care System, San Francisco, California
| | - Allyson Chapman
- Critical Care and Palliative Medicine, University of California, San Francisco
| | - Alexander Smith
- Geriatrics, Palliative, and Extended Care, Veterans Affairs Medical Center, San Francisco, California
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Courtwright AM, Rubin E, Erler KS, Bandini JI, Zwirner M, Cremens MC, McCoy TH, Robinson EM. Experience with a Revised Hospital Policy on Not Offering Cardiopulmonary Resuscitation. HEC Forum 2020; 34:73-88. [PMID: 33136221 DOI: 10.1007/s10730-020-09429-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2020] [Indexed: 11/29/2022]
Abstract
Critical care society guidelines recommend that ethics committees mediate intractable conflict over potentially inappropriate treatment, including Do Not Resuscitate (DNR) status. There are, however, limited data on cases and circumstances in which ethics consultants recommend not offering cardiopulmonary resuscitation (CPR) despite patient or surrogate requests and whether physicians follow these recommendations. This was a retrospective cohort of all adult patients at a large academic medical center for whom an ethics consult was requested for disagreement over DNR status. Patient demographic predictors of ethics consult outcomes were analyzed. In 42 of the 116 cases (36.2%), the patient or surrogate agreed to the clinician recommended DNR order following ethics consultation. In 72 of 74 (97.3%) of the remaining cases, ethics consultants recommended not offering CPR. Physicians went on to write a DNR order without patient/surrogate consent in 57 (79.2%) of those cases. There were no significant differences in age, race/ethnicity, country of origin, or functional status between patients where a DNR order was and was not placed without consent. Physicians were more likely to place a DNR order for patients believed to be imminently dying (p = 0.007). The median time from DNR order to death was 4 days with a 90-day mortality of 88.2%. In this single-center cohort study, there was no evidence that patient demographic factors affected ethics consultants' recommendation to withhold CPR despite patient/surrogate requests. Physicians were most likely to place a DNR order without consent for imminently dying patients.
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Affiliation(s)
- Andrew M Courtwright
- Department of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA
| | - Emily Rubin
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA.,Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kimberly S Erler
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA.,Department of Occupational Therapy, Massachusetts General Hospital Institute of Health Professions, Boston, MA, USA
| | | | - Mary Zwirner
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA.,Social Services, Massachusetts General Hospital, Boston, MA, USA
| | - M Cornelia Cremens
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA.,Departments of Psychiatry and Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas H McCoy
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA.,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Ellen M Robinson
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA. .,Patient Care Services, Massachusetts General Hospital, Boston, MA, 02114, USA.
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4
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Kidd AC, Honney K, Bowker LK, Clark AB, Myint PK, Holland R. Doctors Are Inconsistent in Estimating Survival after CPR and Are Not Using Such Predictions Consistently in Determining DNACPR Decisions. Geriatrics (Basel) 2019; 4:E33. [PMID: 31058832 PMCID: PMC6631017 DOI: 10.3390/geriatrics4020033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 04/22/2019] [Accepted: 04/26/2019] [Indexed: 11/21/2022] Open
Abstract
Background: It is unclear whether doctors base their resuscitation decisions solely on their perceived outcome. Through the use of theoretical scenarios, we aimed to examine the 'do not attempt cardiopulmonary resuscitation' (DNACPR) decision-making. Methods: A questionnaire survey was sent to consultants and specialty trainees across two Norfolk (UK) hospitals during December 2013. The survey included demographic questions and six clinical scenarios with varying prognosis. Participants were asked if they would resuscitate the patient or not. Identical scenarios were then shown in a different order and doctors were asked to quantify patients' estimated chance of survival. Results: A total of 137 individuals (mean age 41 years (SD 7.9%)) responded. The response rate was 69%. Approximately 60% were consultants. We found considerable variation in clinician estimates of median chance of survival. In three out of six of our scenarios, the survival estimated varied from <1% to 95%. There was a statistically significant difference identified in the estimated median survival between those clinicians who would or would not resuscitate in four of the six scenarios presented. Conclusion: This study has highlighted the wide variation between clinicians in their estimates of likely survival and little concordance between clinicians over their resuscitation decisions. The diversity in clinician decision-making should be explored further.
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Affiliation(s)
- Andrew C Kidd
- Glasgow Pleural Disease Unit, Department of Respiratory Medicine, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK.
- Institute of Cancer Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow G12 8QQ, UK.
| | - Katie Honney
- Older People's Medicine, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK.
| | - Lesley K Bowker
- Older People's Medicine, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK.
- Norwich Medical School, Medicine and Health Sciences, University of East Anglia, Norwich NR4 7TJ, UK.
| | - Allan B Clark
- Norwich Medical School, Medicine and Health Sciences, University of East Anglia, Norwich NR4 7TJ, UK.
| | - Phyo K Myint
- Ageing Clinical and Experimental Research (ACER), Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK.
- Department of Medicine for the Elderly, Aberdeen Royal Infirmary, NHS Grampian AB25 2ZN, UK.
| | - Richard Holland
- Leicester Medical School, College of Life Sciences, University of Leicester, Leicester LE1 7RH, UK.
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5
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Robinson EM, Cadge W, Zollfrank AA, Cremens MC, Courtwright AM. After the DNR:Surrogates Who Persist in Requesting Cardiopulmonary Resuscitation. Hastings Cent Rep 2017; 47:10-19. [DOI: 10.1002/hast.664] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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6
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Cardiopulmonary Resuscitation in Resource-limited Health Systems-Considerations for Training and Delivery. Prehosp Disaster Med 2014; 30:97-101. [PMID: 25407562 DOI: 10.1017/s1049023x14001265] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In the past 50 years, cardiopulmonary resuscitation (CPR) has gained widespread recognition as a life-saving skill that can be taught successfully to the general public. Cardiopulmonary resuscitation can be considered a cost-effective intervention that requires minimal classroom training and low-cost equipment and supplies; it is commonly taught throughout much of the developed world. But, the simplicity of CPR training and its access for the general public may be misleading, as outcomes for patients in cardiopulmonary arrest are poor and survival is dependent upon a comprehensive "chain-of-survival," which is something not achieved easily in resource-limited health care settings. In addition to the significant financial and physical resources needed to both train and develop basic CPR capabilities within a community, there is a range of ethical questions that should also be considered. This report describes some of the financial and ethical challenges that might result from CPR training in low- and middle-income countries (LMICs). It is determined that for many health care systems, CPR training may have financial and ethically-deleterious, unintended consequences. Evidence shows Basic Life Support (BLS) skills training in a community is an effective intervention to improve public health. But, health care systems with limited resources should include CPR training only after considering the full implications of that intervention.
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Courtwright AM, Brackett S, Cadge W, Krakauer EL, Robinson EM. Experience with a hospital policy on not offering cardiopulmonary resuscitation when believed more harmful than beneficial. J Crit Care 2014; 30:173-7. [PMID: 25457115 DOI: 10.1016/j.jcrc.2014.10.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 10/04/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE This study investigated the impact of age, race, and functional status on decisions not to offer cardiopulmonary resuscitation (CPR) despite patient or surrogate requests that CPR be performed. METHODS This was a retrospective cohort study of all ethics committee consultations between 2007 and 2013 at a large academic hospital with a not offering CPR policy. RESULTS There were 134 cases of disagreement over whether to provide CPR. In 45 cases (33.6%), the patient or surrogate agreed to a do-not-resuscitate (DNR) order after initial ethics consultation. In 67 (75.3%) of the remaining 89 cases, the ethics committee recommended not offering CPR. In the other 22 (24.7%) cases, the ethics committee recommended offering CPR. There was no significant relationship between age, race, or functional status and the recommendation not to offer CPR. Patients who were not offered CPR were more likely to be critically ill (61.2% vs 18.2%, P < .001). The 90-day mortality rate among patients who were not offered CPR was 90.2%. CONCLUSIONS There was no association between age, race, or functional status and the decision not to offer CPR made in consultation with an ethics committee. Orders to withhold CPR were more common among critically ill patients.
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Affiliation(s)
- Andrew M Courtwright
- Patient Care Services, Institute for Patient Care, Massachusetts General Hospital, Boston, MA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA.
| | - Sharon Brackett
- Patient Care Services, Ellison 4 Surgical Intensive Care Unit, Massachusetts General Hospital, Boston, MA
| | - Wendy Cadge
- Department of Sociology, Brandeis University, Waltham, MA
| | - Eric L Krakauer
- Division of Palliative Care, Massachusetts General Hospital, Boston, MA; Departments of Medicine and of Global Health & Social Medicine, Harvard Medical School, Boston, MA
| | - Ellen M Robinson
- Patient Care Services, Institute for Patient Care, Massachusetts General Hospital, Boston, MA; Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, MA
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8
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Skold A, Lesandrini J, Gorbatkin S. Ethics and health policy of dialyzing a patient in a persistent vegetative state. Clin J Am Soc Nephrol 2014; 9:366-70. [PMID: 24115197 PMCID: PMC3913231 DOI: 10.2215/cjn.03410313] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Each year, out-of-hospital cardiac arrests occur in approximately 300,000 Americans. Of these patients, less than 10% survive. Survivors often live with neurologic impairments that neurologists classify as anoxic-ischemic encephalopathy (AIE). Neurologic impairments under AIE can vary widely, each with unique outcomes. According to the American Academy of Neurology Practice Parameter paper, the definition of poor outcome in AIE includes death, persistent vegetative state (PVS), or severe disability requiring full nursing care 6 months after event. In a recent survey, participants deemed an outcome of PVS as "worse than dead." Lay persons' assessments of quality of life for those in a PVS provide assistance for surrogate decision-makers who are confronted with the clinical decision-making for a loved one in a PVS, whereas clinical practice guidelines help health care providers to make decisions with patients and/or families. In 2000, the Renal Physicians Association and the American Society of Nephrology published a clinical practice guideline, "Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis." In 2010, after advances in research, a second edition of the guideline was published. The updated guideline confirmed the recommendation to withhold or withdraw ongoing dialysis in "patients with irreversible, profound neurological impairments such that they lack signs of thought, sensation, purposeful behavior and awareness of self and environment," such as found in patients with PVS. Here, the authors discuss the applicability of this guideline to patients in a PVS. In addition, they build on the guideline's conception of shared decision-making and discuss how continued dialysis violates ethical and legal principles of care in patients in a PVS.
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Affiliation(s)
- Anna Skold
- Palliative Care and Internal Medicine, Southeastern Permanente Medical Group, Inc., Atlanta, Georgia
| | | | - Steven Gorbatkin
- Nephrology, Atlanta Veterans Affairs Medical Center and Emory University, Atlanta, Georgia
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Kjørstad OJ, Haugen DF. Cardiopulmonary resuscitation in palliative care cancer patients. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2013; 133:417-21. [PMID: 23423208 DOI: 10.4045/tidsskr.12.0378] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND The criteria for refraining from cardiopulmonary resuscitation in palliative care cancer patients are based on patients' right to refuse treatment and the duty of the treating personnel not to exacerbate their suffering and not to administer futile treatment. When is cardiopulmonary resuscitation futile in these patients? METHOD Systematic literature searches were conducted in PubMed for the period 1989-2010 on the results of in-hospital cardiopulmonary resuscitation in advanced cancer patients and on factors that affected the results of CPR when special mention was made of cancer. The searches yielded 333 hits and 18 included articles: four meta-analyses, eight retrospective clinical studies, and six review articles. RESULTS Cancer patients had a poorer post-CPR survival than non-cancer patients. Survival declined with increasing extent of the cancer disease. Widespread and therapy-resistant cancer disease coupled with a performance status lower than WHO 2 or a PAM score (Pre-Arrest Morbidity Index) of above 8 was regarded as inconsistent with survival after cardiopulmonary resuscitation. INTERPRETATION Cardiopulmonary resuscitation is futile for in-hospital cancer patients with widespread incurable disease and poor performance status.
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Abstract
AbstractCardiopulmonary resuscitation is taught widely to both lay persons and health care oworkers. It is a challenging psychomotor skill. Concerns about its safety to the rescuer have centered around the risk of infectious disease exposure. A young nursing assistant developed a minimally symptomatic pneumothorax during CPR training. This case is the first reported example of this complication for a CPR trainee or provider. The literature is reviewed for complications for CPR provider and recipient and the relevant issues regarding the current status and future direction of this intervention.
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We Meant No Harm, Yet We Made a Mistake; Why Not Apologize for it? A Student’s View. HEC Forum 2010; 22:159-69. [DOI: 10.1007/s10730-010-9131-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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12
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Scripko PD, Greer DM. Practical considerations for reviving the CPR/DNR conversation. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2010; 10:74-75. [PMID: 20077349 DOI: 10.1080/15265160903460889] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Patricia Diane Scripko
- Cleveland Clinic Lerner College of Medicine, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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13
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Abstract
Decision making near the end of life can be complex and laden with emotion for families and health care providers. Families and patients can prepare themselves for these difficult moments by thinking ahead about the patient's wishes and preparing clear documents that express those wishes. Health care providers can prepare themselves by being familiar with those documents, considering the goals of treatment, remembering the principles on which health care ethics are founded and knowing decision-making models that will help them to think through treatment plans and the best options for patient taking into consideration the goals of treatment.
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Affiliation(s)
- Terri A Schmidt
- Department of Emergency Medicine, Center for Ethics in Health Care, Oregon Health & Sciences University, CDW-EM, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
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15
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Abstract
Age alone does not at all preclude the possibility of warranted, effective, and successful intensive care. From a medical perspective, the key issue is the reversibility or otherwise of an acute illness and where this illness sits in the trajectory of that individual's life and possible death. It makes no more sense to admit a 19-year-old let alone a 91-year-old to an intensive care unit if intensive care cannot provide what is needed. Of paramount importance in our consideration of critical care for the elderly is a determination and an understanding of the many needs--medical, emotional, social, spiritual, psychologic--that elderly people have. By exploring them with compassion and sensitivity, we can establish whether the goals of care include critical care and the associated technology, or whether alternative and more conservative approaches more closely reflect the values and preferences of an increasingly elderly population.
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Affiliation(s)
- Graeme Rocker
- Dalhousie University, Halifax Infirmary, #4457, 1796 Summer Street, Halifax, Nova Scotia, B3H 3A7 Canada.
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Levack P. Editorial I: Live and let die? A structured approach to decision-making about resuscitation. Br J Anaesth 2002. [DOI: 10.1093/bja/89.5.683] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Reid C, Jeffrey D. Do not attempt resuscitation decisions in a cancer centre: addressing difficult ethical and communication issues. Br J Cancer 2002; 86:1057-60. [PMID: 11953848 PMCID: PMC2364183 DOI: 10.1038/sj.bjc.6600205] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2001] [Revised: 01/06/2002] [Accepted: 01/22/2002] [Indexed: 11/20/2022] Open
Abstract
Talking to patients about 'Do Not Attempt Resuscitation' decisions is difficult for many doctors. Communication about 'Do Not Attempt Resuscitation' decisions should occur as part of a wider discussion of treatment goals at an earlier stage in the patient's illness. A doctor should not initiate any treatment, including cardio-pulmonary resuscitation if he/she does not believe it will benefit the patient. An ethical framework is offered which may be of practical help in clarifying decision-making.
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Affiliation(s)
- C Reid
- Three Counties Cancer Network, Cheltenham General Hospital, Cheltenham G53 7AN, UK
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Ditillo BA. Should there be a choice for cardiopulmonary resuscitation when death is expected? Revisiting an old idea whose time is yet to come. J Palliat Med 2002; 5:107-16. [PMID: 11839233 DOI: 10.1089/10966210252785079] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Since closed chest cardiac massage was introduced in 1960, the notion that cardiopulmonary resuscitation (CPR) attempts are not appropriate for all patients has been consistent. Over the years, leading authorities have clearly articulated that for patients who are dying irreversibly and expectedly medical decisions for do-not-resuscitate (DNR) orders should be made by physicians, because in such cases CPR attempts are not indicated. Physicians are not obligated to and should not offer or provide useless treatments, even in the name of patient autonomy. Despite this, physicians still seek and obtain patient or proxy consent when CPR is not indicated before writing a DNR order. Reasons include fear of legal repercussions/misconceptions, limited physician-patient relationships, time constraints, and institutional culture. End-of-life plans of care should be based on appropriate goals that focus on palliation and not on aggressive medical treatments that offer no benefit.
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Robinson EM. An ethical analysis of cardiopulmonary resuscitation for elders in acute care. AACN CLINICAL ISSUES 2002; 13:132-44. [PMID: 11852719 DOI: 10.1097/00044067-200202000-00013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Despite empirical evidence that cardiopulmonary resuscitation (CPR) is of questionable effectiveness in elders with comorbidities, it continues to hold a unique place in the armamentarium of life-sustaining treatments in that consent for CPR is implied and, when needed, is administered emergently. These conditions of implied consent and emergency implementation often preclude an opportunity for patients/surrogates, in conjunction with their nurses and physicians, to determine the appropriateness of the intervention, given the patient's medical and functional status. Healthcare providers who perform CPR on elderly patients often find themselves in morally distressing circumstances because of their anecdotal knowledge of poor outcomes and realization that a multitude of barriers has precluded an anticipatory discussion regarding appropriateness of the treatment. Nurses and other healthcare providers must take the lead in helping patients/surrogates appreciate the meaning of CPR as a life-sustaining intervention and ensure that each patient's situation receives the ethical reflection deserved for each individual as a matter of human dignity.
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Affiliation(s)
- Ellen M Robinson
- Patient Care Services, Massachusetts General Hospital, Boston, MA 02114, USA.
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Abstract
If patients are to benefit from resuscitation, they must regain consciousness and their full faculties. In recent years, we have acquired important information about the natural history of neurological recovery from circulatory arrest. There are clinical tests that predict the outcome, both during ongoing cardiopulmonary resuscitation (CPR) and in the period after restoration of spontaneous circulation. The ability to predict neurological outcome at this stage offers a basis for certain ethical considerations, which are not exclusively centered on "do-not-attempt-resuscitation" (DNAR)- orders. Instead of being forced to make the decision that "I do not want CPR", the patient should be able to decide that "I want resuscitation to be discontinued, if you predict that I will not recover to a level of neurological function that is acceptable to me". Ideally, no competent patient should be given a DNAR-status without his or her consent. No CPR-attempt should be stopped, and no treatment decision for a patient recovering after CPR should be taken without knowing and assessing the available information. Good ethical decision-making requires reliable facts, which we now know are available.
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Affiliation(s)
- S Holm
- Department of Medical Philosophy and Clinical Theory, University of Copenhagen, DK-2200 N, Denmark
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22
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Abstract
"Futility" is a word which means the absence of benefit. It has been used to describe an absence of utility in resuscitation endeavours but it fails to do this. Futility does not consider the harms of resuscitation and we should consider the balance of benefit and harm that results from our resuscitation endeavours. If a resuscitation is futile then any harm that ensues will bring about an unfavourable benefit/harm balance. However, even if the endeavour is not futile, by any definition, the benefit/harm balance may still be unfavourable if the harms that ensue are great. It is unlikely that we will ever achieve a consensus definition of futility and certainly not one that is applicable to every patient undergoing resuscitation. In the meantime our use of the term "futile", in the mistaken belief that it tells us whether it is worth resuscitating or not, has no utility as it will never succeed in telling us this. Furthermore we risk causing offence by use of the term and we risk harming the patient's autonomy by using futility as an overriding force. Instead we should consider the utility of our endeavours, for which an assessment of the harms of resuscitation should be added to our considerations of its benefit. This balance of benefit and harm should then be evaluated as best it can be from the patient's perspective. The words futile and futility should be abandoned by resuscitationists.
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Affiliation(s)
- M Ardagh
- Christchurch School of Medicine, New Zealand
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23
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Dickenson DL. Are medical ethicists out of touch? Practitioner attitudes in the US and UK towards decisions at the end of life. JOURNAL OF MEDICAL ETHICS 2000; 26:254-60. [PMID: 10951920 PMCID: PMC1733246 DOI: 10.1136/jme.26.4.254] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
OBJECTIVES To assess whether UK and US health care professionals share the views of medical ethicists about medical futility, withdrawing/withholding treatment, ordinary/extraordinary interventions, and the doctrine of double effect. DESIGN, SUBJECTS AND SETTING A 138-item attitudinal questionnaire completed by 469 UK nurses studying the Open University course on "Death and Dying" was compared with a similar questionnaire administered to 759 US nurses and 687 US doctors taking the Hastings Center course on "Decisions near the End of Life". RESULTS Practitioners accept the relevance of concepts widely disparaged by bioethicists: double effect, medical futility, and the distinctions between heroic/ordinary interventions and withholding/withdrawing treatment. Within the UK nurses' group a "rationalist" axis of respondents who describe themselves as having "no religion" are closer to the bioethics consensus on withholding and withdrawing treatment. CONCLUSIONS Professionals' beliefs differ substantially from the recommendations of their professional bodies and from majority opinion in bioethics. Bioethicists should be cautious about assuming that their opinions will be readily accepted by practitioners.
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Ardagh M. Resurrecting autonomy during resuscitation--the concept of professional substituted judgment. JOURNAL OF MEDICAL ETHICS 1999; 25:375-378. [PMID: 10536760 PMCID: PMC479261 DOI: 10.1136/jme.25.5.375] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The urgency of the resuscitation and the impaired ability of the patient to make a reasonable autonomous decision both conspire against adequate consideration of the principles of medical ethics. Informed consent is usually not possible for these reasons and this leads many to consider that consent is not required for resuscitation, because resuscitation brings benefit and prevents harm and because the patient is not in a position to give or withhold consent. However, consent for resuscitation is required and the common models employed for this purpose are presumed consent or consent from a patient proxy. However, if we are to honour the principles of respect for patient autonomy, as well as beneficence and non-maleficence, when starting and continuing resuscitation we must try and achieve the best balance between benefit and harm from the patient's perspective. The concept of professional substituted judgment involves the resuscitators gathering as much information about the patient as they possibly can, including any previously expressed attitudes towards such a situation, and combining this with their acquired professional knowledge of the likely benefits and harms of the resuscitation endeavour and then exercising their moral imagination, imagining themselves as the patient, and asking "would I want this treatment?" By employing professional substituted judgment resuscitators should recognise when the balance of benefit and harm becomes unfavourable from the patient's perspective and at this point they have a moral obligation to withdraw resuscitation as they can no longer presume the patient's consent. In this way the principles of beneficence, non-maleficence and respect for patient autonomy are more favourably balanced than under other resuscitation decision making processes.
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Affiliation(s)
- M Ardagh
- Christchurch Hospital, New Zealand
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26
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Grace RF. Decision making in CPR. Med J Aust 1999; 170:45; author reply 45-6. [PMID: 10026674 DOI: 10.5694/j.1326-5377.1999.tb126868.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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