Skip to main content
SpringerLink
Log in

Experience with a Revised Hospital Policy on Not Offering Cardiopulmonary Resuscitation

  • Published:
HEC Forum Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Data Availability

The data that support the findings of this study are not publicly available due to the presences of protected health information that could compromise subject privacy.

References

  • Biegler, P. (2003). Should patient consent be required to write a do not resuscitate order? Journal of Medical Ethics, 29(6), 359–363.

    Article  Google Scholar 

  • Blinderman, C. D., Krakauer, E. L., & Solomon, M. Z. (2012). Time to revise the approach to determining cardiopulmonary resuscitation status. JAMA, 307(9), 917–918.

    Article  Google Scholar 

  • Bossaert, L. L., Perkins, G. D., Askitopoulou, H., Raffay, V. I., Greif, R., Haywood, K. L., et al. (2015). European Resuscitation Council Guidelines for Resuscitation 2015: Section 11. The Ethics of Resuscitation and End-of-Life Decisions, 95, 302–311.

    Google Scholar 

  • Bosslet, G. T., Pope, T. M., Rubenfeld, G. D., Lo, B., Truog, R. D., Rushton, C. H., et al. (2015). An official ATS/AACN/ACCP/ESICM/SCCM policy statement: Responding to requests for potentially inappropriate treatments in intensive care units. American Journal of Respiratory and Critical Care Medicine, 191(11), 1318–1330.

    Article  Google Scholar 

  • Brennan, T. A. (1988). Ethics committees and decisions to limit care: The experience at the Massachusetts General Hospital. JAMA, 260(6), 803–807.

    Article  Google Scholar 

  • Casarett, D., & Siegler, M. (1999). Unilateral do-not-attempt-resuscitation orders and ethics consultation: A case series. Critical Care Medicine, 27(6), 1116–1120.

    Article  Google Scholar 

  • Council on Ethical and Judicial Affairs. (1999). Medical futility in end-of-life care. JAMA, 281(10), 937–941.

    Article  Google Scholar 

  • Courtwright, A. M., Brackett, S., Cadge, W., Krakauer, E. L., & Robinson, E. M. (2015). Experience with a hospital policy on not offering cardiopulmonary resuscitation when believed more harmful than beneficial. Journal of Critical Care, 30(1), 173–177.

    Article  Google Scholar 

  • de Asúa, D. R., Lee, K., Koch, P., de Melo-Martín, I., & Bibler, T. (2019). We don’t need unilateral DNRs: Taking informed non-dissent one step further. Journal of Medical Ethics, 45(5), 314–317.

    Article  Google Scholar 

  • Dzeng, E., Colaianni, A., Roland, M., Chander, G., Smith, T. J., Kelly, M. P., et al. (2015). Influence of institutional culture and policies on do-not-resuscitate decision making at the end of life. JAMA Internal Medicine, 175(5), 812–819.

    Article  Google Scholar 

  • Ebrahim, S. (2000). Do not resuscitate decisions: Flogging dead horses or a dignified death?: Resuscitation should not be withheld from elderly people without discussion. British Medical Journal, 320(7243), 1155–1156.

    Article  Google Scholar 

  • Fowler, R. A., Noyahr, L. A., Thornton, J. D., Pinto, R., Kahn, J. M., Adhikari, N. K., et al. (2010). An official American Thoracic Society systematic review: The association between health insurance status and access, care delivery, and outcomes for patients who are critically ill. American Journal of Respiratory and Critical Care Medicine, 181(9), 1003–1011.

    Article  Google Scholar 

  • Geocadin, R. G., Peberdy, M. A., & Lazar, R. M. (2012). Poor survival after cardiac arrest resuscitation: A self-fulfilling prophecy or biologic destiny? Critical Care Medicine, 40(3), 979–980.

    Article  Google Scholar 

  • Halbert, C. H., Armstrong, K., Gandy, O. H., & Shaker, L. (2006). Racial differences in trust in health care providers. Archives of Internal Medicine, 166(8), 896–901.

    Article  Google Scholar 

  • Hamel, M. B., Teno, J. M., Goldman, L., Lynn, J., Davis, R. B., Galanos, A. N., et al. (1999). Patient age and decisions to withhold life-sustaining treatments from seriously ill, hospitalized adults. Annals of Internal Medicine, 130(2), 116–125.

    Article  Google Scholar 

  • Hilberman, M., Kutner, J., Parsons, D., & Murphy, D. J. (1997). Marginally effective medical care: Ethical analysis of issues in cardiopulmonary resuscitation (CPR). Journal of Medical Ethics, 23(6), 361–367.

    Article  Google Scholar 

  • Hogue, C. J., Hargraves, M. A., & Collins, K. S. (2000). Minority health in America: Findings and policy implications from the Commonwealth Fund Minority Health Survey. Johns Hopkins University Press.

  • Huynh, T. N., Kleerup, E. C., Wiley, J. F., Savitsky, T. D., Guse, D., Garber, B. J., et al. (2013). The frequency and cost of treatment perceived to be futile in critical care. JAMA Internal Medicine, 173(20), 1887–1894.

    Article  Google Scholar 

  • Jain, A., Jain, M., Bellolio, M. F., Schears, R. M., Rabinstein, A. A., & Ganti, L. (2013). Is early DNR a self-fulfilling prophecy for patients with spontaneous intracerebral hemorrhage? Neurocritical Care, 19(3), 342–346.

    Article  Google Scholar 

  • Kon, A. A., Shepard, E. K., Sederstrom, N. O., Swoboda, S. M., Marshall, M. F., Birriel, B., et al. (2016). Defining futile and potentially inappropriate interventions: A policy statement from the Society of Critical Care Medicine Ethics Committee. Critical Care Medicine, 44(9), 1769–1774.

    Article  Google Scholar 

  • Lantos, J., Matlock, A. M., & Wendler, D. (2011). Clinician integrity and limits to patient autonomy. JAMA, 305(5), 495–499.

    Article  Google Scholar 

  • Lo, B., Saika, G., Strull, W., Thomas, E., & Showstack, J. (1985). 'Do not resuscitate’decisions: A prospective study at three teaching hospitals. Archives of Internal Medicine, 145(6), 1115–1117.

    Article  Google Scholar 

  • Muni, S., Engelberg, R. A., Treece, P. D., Dotolo, D., & Curtis, J. R. (2011). The influence of race/ethnicity and socioeconomic status on end-of-life care in the ICU. Chest, 139(5), 1025–1033.

    Article  Google Scholar 

  • Okhuysen-Cawley, R., McPherson, M. L., & Jefferson, L. S. (2007). Institutional policies on determination of medically inappropriate interventions: Use in five pediatric patients. Pediatric Critical Care Medicine, 8(3), 225–230.

    Article  Google Scholar 

  • Reignier, J., Dumont, R., Katsahian, S., Martin-Lefevre, L., Renard, B., Fiancette, M., et al. (2008). Patient-related factors and circumstances surrounding decisions to forego life-sustaining treatment, including intensive care unit admission refusal. Critical Care Medicine, 36(7), 2076–2083.

    Article  Google Scholar 

  • Robinson, E. M., Cage, W., Erler, K., Brackett, S., Bandini, J., Cist, A., et al. (2017). Structure, operation, and experience of clinical ethics consultation 2007–2013: A report from the Massachusetts General Hospital optimum care committee. The Journal of Clinical Ethics, 28(2), 137–152.

    Google Scholar 

  • Robinson, E. M., Cadge, W., Zollfrank, A. A., Cremens, M. C., & Courtwright, A. M. (2017). After the DNR: Surrogates who persist in requesting cardiopulmonary resuscitation. Hastings Center Report, 47(1), 10–19.

    Article  Google Scholar 

  • Roley, S., DeLany, J. V., Barrows, C., Honaker, D., Sava, D., & Talley, V. (2008). Occupational therapy practice framework: Domain and process. The American Occupational Therapy Association, 62(6), 625–683.

    Article  Google Scholar 

  • Schneiderman, L. J., Jecker, N. S., & Jonsen, A. R. (1990). Medical futility: Its meaning and ethical implications. Annals of Internal Medicine, 112(12), 949–954.

    Article  Google Scholar 

  • Smith, A. K., Davis, R. B., & Krakauer, E. L. (2007). Differences in the quality of the patient–physician relationship among terminally ill African-American and White patients: Impact on advance care planning and treatment preferences. Journal of General Internal Medicine, 22(11), 1579–1582.

    Article  Google Scholar 

  • Smith, M. L., Gremillion, G., Slomka, J., & Warneke, C. L. (2007). Texas hospitals’ experience with the Texas advance directives act. Critical care medicine, 35(5), 1271–1276.

    Article  Google Scholar 

  • Wendler, D. (2010). Are physicians obligated always to act in the patient’s best interests? Journal of Medical Ethics, 36(2), 66–70.

    Article  Google Scholar 

  • Werth, J. L., Jr. (2005). Concerns about decisions related to withholding/withdrawing life-sustaining treatment and futility for persons with disabilities. Journal of Disability Policy Studies, 16(1), 31–37.

    Article  Google Scholar 

  • Wilkinson, D. (2009). The self-fulfilling prophecy in intensive care. Theoretical Medicine and Bioethics, 30(6), 401–410.

    Article  Google Scholar 

  • Wojtasiewicz, M. E. (2006). Damage compounded: Disparities, distrust, and disparate impact in end-of-life conflict resolution policies. The American Journal of Bioethics, 6(5), 8–12.

    Article  Google Scholar 

Download references

Funding

None.

Author information

Authors and Affiliations

  1. Department of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA

    Andrew M. Courtwright

  2. Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA

    Andrew M. Courtwright, Emily Rubin, Kimberly S. Erler, Mary Zwirner, M. Cornelia Cremens, Thomas H. McCoy & Ellen M. Robinson

  3. Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA

    Emily Rubin

  4. Department of Occupational Therapy, Massachusetts General Hospital Institute of Health Professions, Boston, MA, USA

    Kimberly S. Erler

  5. RAND Corporation, Boston, MA, USA

    Julia I. Bandini

  6. Social Services, Massachusetts General Hospital, Boston, MA, USA

    Mary Zwirner

  7. Departments of Psychiatry and Internal Medicine, Massachusetts General Hospital, Boston, MA, USA

    M. Cornelia Cremens

  8. Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA

    Thomas H. McCoy

  9. Patient Care Services, Massachusetts General Hospital, Boston, MA, 02114, USA

    Ellen M. Robinson

Authors
  1. Andrew M. Courtwright
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Emily Rubin
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kimberly S. Erler
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Julia I. Bandini
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Mary Zwirner
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. M. Cornelia Cremens
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Thomas H. McCoy
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Ellen M. Robinson
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ellen M. Robinson.

Ethics declarations

Conflict of interest

The authors have no potential conflicts of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Courtwright, A.M., Rubin, E., Erler, K.S. et al. Experience with a Revised Hospital Policy on Not Offering Cardiopulmonary Resuscitation. HEC Forum 34, 73–88 (2022). https://doi.org/10.1007/s10730-020-09429-1

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10730-020-09429-1

Keywords

Search

Navigation