Hospital and Community Psychiatry September 1992 Vol. 43 No.9 915

Do-Not-Resuscitate Orders forDepressed Psychiatric Inpatients

Linda Ganzini, M.D.Melinda A. Lee, M.D.Ronald T. Heintz, M.D.Joseph D. Bloom, M.D.

Many patients, especially thosewho are elderly and who havechronic medical illnesses, cbvx�se tof orgo cardiopulmonary resuscita-

tion (CPR) in case of cardiac ar-rest. The right ofmentally compet-ent patients to refuse CPR is sup-

ported k� ethicists, the courts, andmedical associations. Psychiatristsare increasingly presented withdikmmas about resuscitation pref-

erences ofelderly psychiatric inpa-tients whose decision-making ca-pacity may be impaired because ofmental illness such as depression.The authors discuss justifications

f orpatients’ refusing resuscitation,

the role of advance directives incommunicating patients’ preferen-

ces, and the use of do-not-resusci-tate ordersfor depressed psychiatricinpatients. Survival rates after

CPR among elderly patients with

chronic medical illnesses are low.

Dr. Ganzini is director of geriatric

psychiatry and Dr. Lee is a staff

geriatrician at the Veterans Af-

fairs Medical Center (1 16A-P),P.O. Box 1034, Portland, Oregon97207. Dr. Ganzini is also assis-

tant professor of psychiatry atOregon Health Sciences Univer-sity, where Dr. Lee is � assistant

professor of medicine, Dr. Heintz

is adjunct assistant professor of

psychiatry, and Dr. Bloom is pro-fessor and chair of the depart-ment of psychiatry. Dr. Heintz isalso supervising psychiatrist atDammasch (Ore.) State Hospital.

Patients and their families need

accurate information about therisks and benefits of CPR andabout the consequences of refusingthe procedure.

In recent decades, medical progresshas made it possible to sustain life

through a variety of technologicalmeans, such as cardiopulmonary re-

suscitation (CPR) and advanced car-diac life support. However, many pa-tients choose to forgo CPR in the

case ofcardiac arrest. On medical in-patient services, determination ofpatients’ resuscitation preferences is

now commonplace.Psychiatrists increasingly care for

patients who are physically as well asmentally ill. The number ofaged pa-tients has increased, and psychia-tnists now treat many elderly pa-

tients with chronic and debilitatingmedical illnesses on inpatient psy-

chiatnic units (1,2). For some pa-tients the question of resuscitation

status arises.In this paper we discuss con-

siderations in determining the resus-citation status of psychiatric in-patients and the role of advance di-rectives in communicating patients’

preferences about resuscitation. Wepresent three case vignettes thatposed dilemmas about the use of do-

not-resuscitate orders for depressed,elderly psychiatric inpatients.

Justification forforgoing CPRCPR was originally developed in the1 960s for treatment of cardiac arrestin otherwise healthy victims of acutemedical illness (3). Since that time,the use of CPR has expanded, be-coming a mandate for all patientswho experience cardiac arrest regard-

less of their underlying disease pro-cesses (4). Cardiac arrest precedes all

deaths, and unless CPR is specifically

proscribed, it is routinely performedon dying patients in hospitals. CPRis attempted in about one-third ofthe 2 million patient deaths that

occur in U.S. hospitals each year (5).The indiscniminant use of CPR

has been challenged in the last tenyears. Recent studies have demon-

strated that CPR is futile for manyelderly patients with chronic medi-cal illnesses (4,6-8). For these pa-tients, CPR is not deemed life savingbut death prolonging (9). Results

from patient surveys in many set-tings indicate that CPR and me-chanical ventilation are not desiredby all patients. A study of258 elder-ly outpatients reported that only 36-percent desired both CPR and me-

chanical ventilation in the case ofcardiac arrest (10). A study in GreatBritain found that 47 percent ofmentally competent elderly inpa-

tients did not want resuscitation

(1 1). Among residents of long-term-care facilities, between 38 and 90percent reported that they did notwant CPR (12,13).

There is an ethical and legal con-sensus that mentally competent pa-tients have a right to refuse life-sus-taming therapy, including CPR.

Guidelines of the American MedicalAssociation state that “the physicianhas an ethical obligation to honor theresuscitation preferences expressedby the patient” (5). The right to re-fuse life-sustaining treatment, in-c!uding CPR, was recently reaf-firmed by the U.S. Supreme Court inCruzanv. Director(14).

Determining

patient preferenceIn hospitals and long-term-cane in-stitutions, a mentally competent

patient may request that no CPR be

performed should he or she have a

916 September 1992 Vol. 43 No.9 Hospital and Community Psychiatry

cardiac arrest. Based on an informed

consent model, the patient must beable to understand the nature of CPR

and advanced cardiac life support, its

risks and benefits, the alternatives,

and the consequences of refusing the

procedure. The patient must be freeto choose whether to consent to or re-

fuse the proposed treatment (15,16).

A competent patient’s informed de-

cision is communicated through a do-

not-resuscitate order recorded by thephysician in the medical record (5).

Because mental status changes are

often part ofthe dying process, many

patients have diminished ability toexpress a reasoned, authentic prefer-

ence for or against CPR at the timewhen its need is imminent. In the

Cruzan decision (14), the Supreme

Count supported use of written ad-vance directives, such as a living will

or a durable power of attorney for

health care, to ensure that patients’preferences are communicated for fu-

ture episodes ofdecisional incapacity.Living wills, in general, instruct

the physician to withhold treatments

such as CPR if the patient has a ter-minal illness-that is, less than one

year ofexpected life (17). They are of

limited usefulness because with

many disease processes the length ofremaining life cannot be predictedwith certainty. A durable power ofattorney for health care, now avail-

able in 17 states, allows a competent

patient to assign decision-makingresponsibility for health cane deci-

sions to a surrogate (18). The sun-rogacy becomes effective only if the

patient is either temporarily or per-manently incapacitated.

In 1988 living wills had been cx-

ecuted by only 1 5 percent of Amen-

icans, and fewer than 3 percent had

executed a durable power of attorney

for health care (19). To facilitate theuse of advance directives, in 1990Congress passed the Patient Self-Dc-termination Act (20). This regula-tion was implemented in December

1991 and requires all hospitals (in-

c!uding psychiatric hospitals) thatreceive Medicare or Medicaid to pro-

vide written information to all adult

patients on their rights under statelaw to make decisions about their

medical cane, including the right to

accept or refuse care and the right to

formulate an advance directive. Theinformation must also include in-

stitutional policies for implement-ing these nights.

The Patient Self-Determination

Act also requires hospitals to inquirewhether a patient has executed an ad-vance directive such as a living will

or a durable power of attorney forhealth care. The patient’s response

must be documented. The law ne-quires hospitals to ensure compli-ance with advance directives consis-tent with state law and to avoid dis-cnimination on the basis of whetherthe patient has executed an advancedirective or not. Hospitals must edu-cate staffabout advance directives.

Do-not-resuscitate decisions

for depressed patientsPsychiatrists in general hospitals areincreasingly confronted with ques-tions about the resuscitation status ofpsychiatric inpatients. The JointCommission on Accreditation ofHealthcare Organizations requires

all psychiatric hospitals to have do-not-resuscitate policies (2). In manytypes of psychiatric inpatient set-

tings, advance directives are part of

patients’ permanent hospital record,and thus patients’ preferences are

evident to a!! physicians who care forthem. Patients may be transferred

from medical wards to psychiatricinpatient units with do-not-resus-

citate orders already recorded. ThePatient Self-Determination Act en-courages patients to bring their pref-

erences about resuscitation to theirpsychiatrist’s attention.

However, psychiatrists may not

be as comfortable with patients’ ne-

suscitation preferences as their mcd-ical counterparts are. Do-not-resus-

citate orders on inpatient psychiatricunits may be considered unnecessary

and premature by psychiatrists be-cause dying patients are transferredto medical services. Discussions ofresuscitation preferences may beviewed as countertherapeutic be-

cause they may increase some pa-

tients’ anxiety or hopelessness. Psy-chiatnists may perceive a conflict be-tween honoring a do-not-resuscitate

request and preventing refusals ofcare associated with suicidal ideation(2). Because patients’ ability to rca-

son may be impaired, psychiatrists

may believe that their duty to pro-

tect patients from decisions with po-

tentially irrevocable consequences isparamount.

Depression may impair the capac-

ity to make treatment decisions by

promoting irrational treatment re-

fusals by patients who are hopeless,mistrustful, apathetic, or suicidal.

Hopelessness on delusions associated

with depression may cause the pa-

tient to underestimate the benefit of

treatment. Impaired self-worth or

fear of being a burden to others may

result in treatment refusal. Depres-

sion may also be associated withapathy, ambivalence, and indecision

such that the patient has difficultyexpressing a choice or prematurely

abdicates decision making to a fami-

ly member or a health cane provider.

Refusal of CPR or requests for do-not-resuscitate status may represent

a desire to die and to end the suffer-ing associated with depression (21).

In the psychotically depressed pa-tient, refusal oflife-sustaining proce-

dunes such as CPR may be fueled byparanoid delusions about the proce-

dure on mistrust of medical person-

nd. Ambivalence associated with de-

pression or psychosis may impair the

ability to maintain and communi-

date a stable choice (22).Thus patients with severe emo-

tiona! distress who require psychiat-

nc hospitalization are encouraged to

defer major life decisions until theirmental status improves. Although

patients with depression are cared forin other hospital settings, nonpsy-

chiatnic physicians may view deter-mination of decision-making capaci-

ty more narrowly by giving primary

consideration to a patient’s under-

standing of risks and benefits, with-

out clearly addressing the role of af-

fective disturbances or mistrust inthe patient’s decision (23,24).

Implementation of the Patient

Self-Determination Act will encour-age patients to make known their

preferences about treatment at the

end of!ife. The law gives strong sup-

port for physician compliance withpatients’ wishes. Psychiatrists’ con-

cern for patients’ nights may conflict

with their concern for patients’ well-

being.

Hospital and Community Psychiatry September 1992 Vol. 43 No.9 917

Ethical dilemmas:

case vignettesThe following cases illustrate some

dilemmas we have encountered indetermining resuscitation status of

depressed psychiatric inpatients.The patients in these cases weretreated voluntarily on a university-

affiliated psychiatric inpatient unit.

The first two cases came to our atten-

tion during a research study inves-

tigating the effect of treatment for

depression on patients’ decisions

about life-sustaining interventions.Case 3 was brought to our attention

by psychiatrists who were aware ofour interest in this area.

Case 1 . An elderly, cognitively in-

tact woman was admitted to a gener-al hospital psychiatric unit for treat-ment of severe depression. Sheagreed to participate in a survey

about the effects ofdepression on de-cision-making about life-sustaining

interventions. She was told that the

answers to her questions were con-fidential and nonbinding and would

neither be recorded in hen chart nor

revealed to her health care providers.

She was told that all depressed pa-tients her age on the unit were asked

to participate.Despite these reassurances, she

began to weep after several questions

by the interviewer, saying, “You areasking me these questions because

you believe these things are going to

happen to me, don’t you?”This case illustrates a major con-

cern ofpsychiatrists in determining

patients’ preferences for CPR: suchdiscussions may frighten depressedpatients, reinforce their beliefs thatproviders consider the situationhopeless, and interfere with the ther-

apeutic process of nemoralization.Studies have found that between 13

and 32 percent of general medical

outpatients do not want to discusstheir resuscitation preferences (9,25,26). In one study from which de-

pressed patients were excluded, dis-

cussion ofpreferences regarding life-sustaining procedures caused nega-tive emotions in a significant per-centage ofpatients; 22 percent felt

nervous, and 16 percent felt sad (26).Although it is recommended that

physicians determine patients’ resus-

citation preferences well in advance

of need, routine discussion of resus-

citation with all patients at the time

of admission to a psychiatric in-patient unit may not be appropriateand is not required by the Patient

Self-Determination Act. More ne-search is needed about the impact on

depressed psychiatric inpatients of

routine physician-initiated do-not-

resuscitate discussions.Case 2. A 78-year-old cognitively

intact woman, who had recently un-

dengone a resection of a lung tumor,was admitted for treatment of de-pression to a university psychiatric

unit. She explained that she hadsigned a living will that was on filewith her primary physician, who was

affiliated with the same hospital. Shealso had completed a durable power

ofattorney for health care, designat-ing a friend as her agent in case of fu-

tune incapacity. The patient and thefriend reported that both documents

were executed before the episode of

depression.

On admission to the psychiatricunit, the patient requested do-not-

resuscitate status. Her friend stated

that this desire was consistent with

the patient’s wishes before the onsetof her depressive episode. The at-

tending psychiatrist said he feltobligated to refuse hen request; to

record hen do-not-resuscitate statusin the medical record would be to

“possibly participate in hen murder.”

He believed that should she require

CPR, she had a 60-percent chance ofbeing alive and functionally mdc-

pendeni in three months. Althoughthe psychiatrist accurately defined a

do-not-resuscitate order as meaningthat in case the patient suffered car-

diac arrest, no CPR would be per-formed, he also expressed concerns

that access to intensive care and other

life-sustaining treatments would be

withheld.In this case, the issue of deciding

resuscitation status when a patient is

depressed was further complicatedby the existence of two written ad-vance directives that have statutory

protection. The psychiatrist in this

scenario was placed in a dilemma.

The patient’s agent, designated tomake health care decisions for her

during episodes of decisional in-capacity, may not have recognized

incipient depression as a factor in the

patient’s desire to forgo life-saving

interventions. Alternatively, the de-

sire to forgo resuscitation may havepreceded depression, and thus any

resuscitation attempts would violate

her rights.Further exploration of the pa-

tient’s state of mind at the time she

talked about these matters, their re-

lationship to the onset of depression,

and the stability of her preferences

over months to years may havehelped the psychiatrist resolve his

doubts about the authenticity of her

request. However, although helegitimately questioned the dcci-

sion-making capacity of the patientat the time she completed the docu-ments, in general, physicians are

bound to follow an advance directive.A physician may refuse to honor a

do-not-resuscitate request because of

religious or philosophical beliefs

about the sanctity oflife. The PatientSelf-Determination Act does not

override state laws that allow forhealth care providers, as a matter of

conscience, to refuse to implementan advance directive. In those cases,

the provider must inform the patient

of his or her belief and transfer the

patient to another provider. Ifa phy-sician questions the validity of the

advance directive because of sus-pected patient incompetence at thetime it was executed, he or she must

petition the count to have it re-

scinded (1 8). Some states protect

medical personnel from liability for

refusing to honor an advance direc-

tive. Other states specify sanctions

for failure to follow a directive. Sanc-

tions range from a misdemeanor of-

fense through civilliability and revo-cation of the medical license (27).

This case also demonstrates that

inaccurate knowledge of the risksand benefits of CPR may promote

reluctance to honor a do-not-resus-

citate request. For example, the pay-

chiatnist in this case was reluctant torecord the patient’s resuscitation

preference because he overestimatedthe success rate ofCPR. After CPR is

attempted, only 1 5 to 1 7 percent of

all patients survive until discharge(9). Among elderly patients with

chronic medical illnesses who sufferan in-hospital cardiac arrest, the out-

918 September 1992 Vol. 43 No.9 Hospital and Community Psychiatry

come is uniformly poor; from 0 to 4

percent survive until discharge fromthe hospital (6,8,13). In one study of

294 patients who underwent resus-

citation procedures, no patient with

metastatic cancer, pneumonia, sep-sis, or acute stroke survived until dis-

charge (28). Outcomes are better (14to 30 percent survive until dis-

charge) in healthier, younger popula-tions who suffer ventricular fibrilla-

tion (9).In addition to being overly op-

timistic about the patient’s prog-

nosis, the psychiatrist hesitated be-

cause he incorrectly believed that a

do-not-resusci tate order limitedother treatment options such astreatment in an intensive care unit.

Decisions to forgo CPR can occur

contemporaneously with decisions towithdraw and limit other treat-ments . However, a do-not-resusci-

tate order prohibits only the use ofCPR and does not communicate anyother limitations oftreatment (5,9).

Case 3. A 65-year-old man wasadmitted to a psychiatric inpatient

service for treatment of depressionand refusal to take food, medications,

and fluids. As a result of severalstrokes, he had hemiparesis, dys-

phagia, and decreased visual acuity,

but he was otherwise cognitively in-

tact. Both he and his wife requested

that “ no extraordinary measures betaken should he become more ill,”and on further discussion with the

family a do-not-resuscitate order was

written. Because he had not pre-

viously expressed a preference for do-not-resuscitate status, and because

he had a history of refusing food as aresult of family discord, his treat-ment plan included daily discussions

with him to verify the stability of hispreference for do-not-resuscitate

status.Over the next week, as he was

asked, “Would you like your heartstarted again should it stop beat-ing ? “ his do-not-resuscitate order

was written and rescinded fourtimes. After a week in the hospital,he permanently rescinded the order,

accepted a feeding tube, and beganto participate in therapies. The men-

tal health providers documented that

the patient’s wife continued to dis-

agree with the resuscitation status

throughout the remainder of thepatient’s hospitalization.

The mental health team caring for

the patient understood the dilemma

of balancing the patient’s right toself-determination with their con-

cern that his depression heavily in-fluenced his request for do-not-resuscitate status. The treatment

plan ofasking him every day to con-

sent to or reject CPR perhaps in-

creased the patient’s ambivalence,

with deleterious effect. This degreeof instability of preference indicates

substantial impairment in decision-making capacity (21). Advising thepatient and family that recording the

do-not-resuscitate status in the mcd-ical record should be temporarily

deferred would have been appnopni-ate; however, ongoing discussions arenecessary until a stable preference is

elicited. Webb and Amchin (2)

pointed out that unnc�o!ved dis-agreements about do-not-resuscitate

orders may contribute to deteriona-tion of the therapeutic alliance be-tween the psychiatrist and the pa-

tient and family.The providers in this case could be

faulted for not giving the patient ac-

curate information about the natureofthis procedure and its benefits. Lo

(9) warned against phrasing that

suggests CPR is as simple and effec-

tive as jump-starting an automobile

or changing a fuse. The physicianshould provide an explanation of thenature ofCPR, including chest com-pressions, electrical shock, and in-

tubation, in an explicit manner. The

possible outcomes should be clan-

fled, including the likelihood both ofsuccess and ofadvense outcomes suchas death and irreversible coma.

When a patient is incapacitated,many agree that family members be-

come the most appropriate decisionmakers because they are are the mostknowledgeable about the patient’s

values and preferences (16). In some

states it is lawful for physicians,without a court proceeding, to ob-tam consent from the patient’s rela-tives to withhold treatment from a

terminally ill patient (29). Surrogate

decision makers, whether or not they

are legally entitled through a durable

power of attorney for health cane or

guardianship, should be instructed

to choose what they believe thepatient would choose, if competent,based on previously expressed wishesand known values and beliefs. Ofconcern are studies that show thatspouses’ predictions are no more ac-curate than chance alone in predict-ing what patients would want inhypothetical scenarios ofiliness (10).

Cases in which the surrogate

knowingly recommends actions thatare not consistent with the patient’sdesires are rare, but the physicianmust be alert to the possibility. Phy-sicians are not obligated to complywith requests by legally designatedsurrogates if the physician believesthat there is a conflict of interest on

that the surrogate is acting in badfaith (18,30).

Hospital ethics committees can

be an important source of guidanceand mediation in dilemmas aboutdo-not-resuscitate orders and ad-

vance directives. Their role is most

often advisory, but they can helpclarify the patient’s best interest andprovide support for the parties in-volved in making these difficult de-cisions (12,31). Ifinstitutional mcd-iation fails to resolve a conflict be-tween a surrogate decision maker

and a physician, it is appropriate toseek the assistance ofthe court (18).

ConclusionsPsychiatrists care for many patients,including frail elderly nursing homeresidents, AIDS patients, and oldenadults with chronic mental illness.Decisions about the resuscitationstatus of such patients cannot bepostponed forever. Psychiatrists can-

not abdicate their responsibilities inthis area. CPR is a treatment that isroutinely administered without the

patient’s consent because informedrefusal is required in order to forgothis procedure. But as one authorwrites, “All too often CPR just hap-pens without inquiry into the pa-

ticnt’s wishes or consideration of itschances ofsuccess” (4).

Requests by depressed psychiatricinpatients to forgo resuscitationpresent a clinical dilemma for psy-chiatnists. The desire to forgo CPRmay result from depression. How-

ever, the fact that many patientswithout mental disorders but withchronic debilitating medical condi-

Hospital and Community Psychiatry September 1992 Vol. 43 No.9 919

tions do not desire interventions

such as CPR cannot be overlooked.Depression should not mandate

CPR, nor should it invalidate all de-

cisions about the manner ofone’s in-evitable death. The following guide-lines are suggested pending further

research on the effect of depressionon patients’ decisions about life-sus-

raining interventions.If, in the psychiatrist’s estimation,

the patient’s decision-making capac-

ity is unaffected by depression (or an-

other mental disorder), requests toforgo CPR should be respected andrecorded in the medical record.

If the psychiatrist believes thatdepression is impairing the patient’s

decision-making capacity, ancillary

information should be sought. If adurable power of attorney for health

care exists, the assigned agent should

become the surrogate decision-

maker. If there is no such document,

the patient’s family and primaryphysician should be questionedabout the patient’s previous wishes

and state ofmind when the preferen-

ces were discussed. Ifthe patient haspreviously stated clear wishes re-

garding resuscitation, those wishes

should be honored.Consultation with medical col-

leagues may assist in determining

the benefits of resuscitation. Futile

medical therapy need not be pur-

sued. In addition, ifthe patient has a

living will and the medical colleague

assesses that the patient has a ten-minal illness, do-not-resuscitate

status should be recorded.Deferral ofa decision is appropni-

ate if the patient’s decision-making

capacity is impaired because of de-

pnession, a legally designated sun-rogate decision maker is unavailable,

the patients’ previous wishes are notclearly known, and therapy is not

futile. In such a case, discussions

with the patient should continueuntil a stable, informed, authenticpreference is elicited. In some cases,

consultation with the hospital ethics

committee or legal counsel is appro-

pniate.The Patient Self-Determination

Act encourages patients to initiatediscussions with their physicians

about preferences regarding life-sus-taming therapies such as CPR. Psy-

chiarnists need to increase their know-ledge of advance directives and de-

velop a new level of sophistication in

the use ofdo-not-resuscitate orders.

Acknowledgments

This work was partly supported by theMedical Research Foundation of Ore-gon. The authors thank Jackie Lock-wood for assistance in manuscript prep-aration.

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