CPR/DNR

THE ETHICAL ISSUES

FEATURES TO BE CONSIDERED• REALISTIC ASSESSMENT OF BENEFITS

– RESTORATION OF HEARTBEAT– SURVIVAL TO LEAVE HOSPITAL– RETURN TO PREVIOUS OR DECENT LEVEL OF

FUNCTIONING• ANTICIPATION OF CRISIS --- ADVANCE DIRECTIVE• DISCUSSION WITH PATIENT --- DETERMINATION OF

WISHES• FAMILY INVOLVEMENT --- SURROGATE’S AUTHORITY• SEDUCTIONS OF TECHNOLOGY• CHANGE OF MIND

DNR AND ETHICS• RELATED TO DIGNITY OF PATIENTS

– HONORING AND IDENTIFYING WISHES• PATIENT’S VIEW OF LIFE, DEATH, AND “GOODS”• EXERCISE OF AUTONOMY AND PROXY DECISION MAKING

THROUGH INFORMED CONSENT• PRINCIPLE OF JUSTICE

– TREAT ACCORDING TO ONE’S CONDITION• COMMUNICATION ABOUT OTHER END-OF-LIFE DECISIONS• DISCUSSIONS ABOUT ADVANCE DIRECTIVES• ESTABLISH CONTINUITY OF CARE

CRITERIA FOR CPR/DNR• TO PREVENT SUDDEN, UNEXPECTED DEATH

– COROLLARY: DNR WHEN DEATH IS EXTENDED PROCESS AND/OR EXPECTED

• PRESUMPTION IS GENERALLY IN FAVOR OF CPR UNLESS OTHERWISE INDICATED

• BEST INTERESTS OF THE PATIENT• RESOURCE ALLOCATIONS (@ $2,500-$3,500)• CARDIAC ARREST OCCURS WITH EVERY DEATH

DNR AND AGE• SUCCESS RATE FOR CPR IS ABOUT 33%-

40% ACROSS ALL AGES AND CONDITIONS– 70% OF SURVIVORS DO NOT LEAVE THE

HOSPITAL• 70-79 YEARS --- 12.4% TO DISCHARGE• 80-89 YEARS --- 10.2% TO DISCHARGE• 90+ YEARS --- O% TO DISCHARGE• PRESUMPTION FOR DNR UNLESS

OTHERWISE INDICATED???

DNR COMFORT CARE LAW AND ETHICS• EXPECTATION OF PROCESS OF COMMUNICATION• UTILIZES THE DYNAMICS OF INFORMED CONSENT• ACKNOWLEDGES RIGHT TO REFUSE TREATMENT• EXPLORATION OF PATIENT WISHES RELATED TO THEIR VIEWS OF LIFE

AND DEATH• REINFORCES DIGNITY OF PATIENT AND RESPECT FOR AUTONOMY• RECOGNITION THAT THERE ARE LIMITS TO MEDICAL INTERVENTIONS

– NO LONGER BENEFICIAL• ALLOWS FOR A PEACEFUL DEATH• CAN BEGIN CONSIDERATION OF COMPREHENSIVE AND SPECIFIC

ADVANCE DIRECTIVES– ARTICULATE THE VALUE CONTEXT OF PATIENT– SELECT DIRECTIONS IN TREATMENT CONSISTENT WITH PATIENT’S

VALUE CONTEXT