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Just how far goes DNR?

2008; Elsevier BV; Volume: 48; Issue: 6 Linguagem: Inglês

10.1016/j.jvs.2008.08.038

1097-6809

James W. Jones, Laurence B. McCullough,

Ethics and Legal Issues in Pediatric Healthcare

Mr T. Ragic presented with a thrombosed limb of an aortobifemoral graft placed over 2 decades ago. He has unresectable stage VI lung cancer and do not resuscitate (DNR) orders that were suspended during the thrombectomy. A cardiac arrest resulted in him being in the intensive care unit a day later ventilator-dependent and comatose, and repeated computed tomography scans show severe cerebral edema. He has frequent ventricular dysrhythmias. His eldest daughter is about to deliver his first grandchild, which is the main reason that he requested the procedure to extend his life. In discussions with the family, they express uncertainty about the implications of his DNR order for current treatment. They ask you for your thinking on this matter. Mr T. Ragic presented with a thrombosed limb of an aortobifemoral graft placed over 2 decades ago. He has unresectable stage VI lung cancer and do not resuscitate (DNR) orders that were suspended during the thrombectomy. A cardiac arrest resulted in him being in the intensive care unit a day later ventilator-dependent and comatose, and repeated computed tomography scans show severe cerebral edema. He has frequent ventricular dysrhythmias. His eldest daughter is about to deliver his first grandchild, which is the main reason that he requested the procedure to extend his life. In discussions with the family, they express uncertainty about the implications of his DNR order for current treatment. They ask you for your thinking on this matter. Do not try to live forever. You will not succeed.George Bernard Shaw ADNR clearly was the patient's wish, indicating all therapy must be discontinued.BDNR has no basis in making decisions about current treatment but only to avoid resuscitation. Continue all other indicated therapy.CDNR means that the disastrous operating room resuscitation was unethical.DDNR suspension continues until the aftermath is resolved.EDNR orders result in clinical maltreatment. “End-of-life” euphemizes the beginning of death. Knowledge stops at the end-of-life; death being our universal material finality. Francis Bacon characterized the human emotions associated with death as, “Fear such as a small child has of the darkness.”1Bacon F. Essays and new Atlantis. Walter J Black Inc, Roslyn, NY1943Google Scholar Death motivates the existence of religion, the medical profession, and gravediggers. Many of the world's great monuments, including the Great Pyramids, the Taj Mahal, the Mausoleum at Halicarnassus, Saint Peter's Basilica, and the dynastic tombs of the Shang and the Han, are representations not only of the awe with which we confront death but also of our efforts to magically project life into death and so withstand it. Because of the fear death's ubiquitousness and finality generates, many of ethics' knottiest challenges are associated with end-of-life issues. For most of the history of Western medicine, the standard of care was for physicians not to take on desperate cases in which the physician could reliably predict a high risk of mortality. The correlate of this standard of care was that physicians should stop treating patients who became so desperately ill that they were likely to die. These standards date from the time of the Hippocratic texts, and two important concerns supported them. The first was the physician's self-interest. In a crowded, competitive, completely unregulated market place for medical and surgical services, practitioners who became known for losing their patients would not succeed. High mortality rates were not good for a practitioner's reputation; indeed, high mortality rates would mean financial ruin. Such behavior would be foolhardy, not courageous. The second standard arose from a keen appreciation for the moment when medicine reaches its limits to alter the course of disease. In the Hippocratic text, The Art, the unknown author addresses the topic of whether physicians should continue to treat desperate cases, those in which the limits of medicine to prevent death have been reached. Physicians should discontinue the care of such patients, because to proceed with treatment is a kind of madness. Moreover, in such cases treatment might cause unnecessary and preventable iatrogenic harm to the patient. The mid-20th century became for medical technology what the Cambrian explosion was for species—a perfect storm: enter antibiotics, intensive care units, critical monitoring, ventilators, cardiopulmonary bypass, hyperalimentation, and megadose steroids. It was a no-holds-barred atmosphere as the limits of new technology were tested and retested. But medicine, just as all things biologic, is cyclic, and the Hippocratic warning about overstepping medicine's limits began to be heeded as physicians recovered the ancient wisdom that not every incremental reduction of mortality is worth the suffering that results from failure to acknowledge the limits of medicine. Advance directives are legal instruments through which a patient makes decisions about future life-sustaining treatment that should be respected and implemented when the patient is, in the attending physician's clinical judgment, no longer able to make decisions. The living will or directive to physicians is used to instruct physicians about the administration or withholding of life-sustaining treatment when the patient has lost decision-making capacity and has a terminal or irreversible condition (as defined in applicable statutory law). Either through a directive to physicians or through a medical power of attorney, a surgeon may be validly instructed in advance by a patient with a terminal condition that he or she does not want life-sustaining treatment administered, especially resuscitation. Nevertheless, it is sometimes the case that a terminally ill patient can benefit clinically from surgical management of problem. When this issue first surfaced about 15 years ago, some argued that DNR orders should be as applicable in the operating room as they are anywhere else in the hospital.2Walter R. DNR in the OR: resuscitation as an operative risk.JAMA. 1991; 266: 2407-2412Crossref PubMed Scopus (64) Google Scholar The argument in support of this position appeals to the ethical principle of respect for autonomy. This principle was understood to mean that the informed preferences of patients regarding end-of-life care should guide physicians' clinical judgment in all clinical settings. Otherwise, advance directives would have little meaning if surgeons could simply override directives at the surgeon's discretion. Others argued that DNR orders should be suspended in all cases when a patient was taken to surgery.3Youngner S. Shuck J. Advance directives and the determination of death.in: McCullough L.B. Jones J.W. Brody B.A. Surgical ethics. Oxford University Press, New York, NY1998: 57-77Google Scholar Anesthesiologists and surgeons quite reasonably took the view that intraoperative arrest of a seriously or terminally ill patient should be regarded as a correctable side effect of anesthesia and not a function of the patient's underlying disease or injury. Moreover, intraoperative resuscitation maintains homeostasis and patients usually recover, in sharp contrast to the overall low success rate of resuscitation elsewhere in the hospital. It is inconsistent with the professional integrity of surgical clinical judgment and practice to withhold an intervention that is effective in achieving the goals of surgery. Seriously or terminally ill patients who consent to surgery can reasonably be presumed to want its functional improvements and palliative effects, but they will not experience these outcomes if an intervention that is usually effective in helping to achieve them is withheld. In short, a strong case can be made on both clinical grounds and on the basis of a reasonable assumption about patients' preferences that DNR orders should be suspended during surgery for seriously ill or terminally ill patients. It is not enough, however, to take the view that DNR orders should be suspended in the operating room or because this position does not address the important ethical question of when DNR should be reinstated postoperatively. There has emerged a consensus view that DNR status should be restored when life-threatening events are reliably judged to be owed to the patient's underlying terminal condition rather than to anesthesia, surgery, and their immediate side effects.4Wear S. Milch R. Weaver W. Care of dying patients.in: McCullough L.B. Jones J.W. Brody B.A. Surgical ethics. Oxford University Press, New York, NY1998: 171-197Google Scholar In the present case, a ruinous complication has blurred the moral horizon. DNR orders mean exactly what the phrase states: Do not initiate a cardiopulmonary resuscitation. Unlike much of the concern when the concept originated, it does not mean to withhold or scrimp indicated therapy. Discontinuance of therapy, whether life-supporting or not, is a separate issue. Option A is wrong. Option C, condemning the suspension of DNR orders because of the possible disaster it allowed is irrational. As mentioned, the major rationale for DNR suspension during surgical therapy is to maximize the success of the therapy by allowing treatment of untoward effects in an atmosphere where resuscitation is likely to be successful. The suspension ends when the operative therapy, including perioperative care, is over. Option D is incorrect. Quite the contrary to option E, DNR is widely considered to be an ethical mandate from the standpoint of patient autonomy and allocation of resources. The College of Surgeons policy states: Some patients with DNR status become candidates for surgical procedures that may provide them with significant benefit even though the procedure may not change the natural history of the underlying disease … When such patients undergo surgical procedures and the accompanying sedation or anesthesia, they are subjected to new and potentially correctable risks of cardiopulmonary arrest. Furthermore, many of the therapeutic actions employed in resuscitation (for example, intubation, mechanical ventilation, and administration of vasoactive drugs) are also an integral part of anesthetic management. The DNR status of such patients during the operative procedure and during the immediate postoperative period may need to be modified prior to operation.”5[St 19] Statement of the American College of Surgeons on Advance Directives by Patients “Do Not Resuscitate” in the operating room.Bull Am Coll Surg. 1994; 79: 29Google Scholar Option B is the best choice. Therapeutic indications and contraindications are independent of whether or not a DNR order is in place. The focus of clinical judgment and recommendations to the family based on it should be on the two goals of surgical critical care. The short-term goal of surgical critical care is to prevent imminent death, which continued treatment is reasonably expected to accomplish. The long-term goal of critical care is an acceptable outcome, viewed either from the patient's or the physician's perspective. In this case, there is no ethical obligation to maintain human physiology when the patient is no longer capable of using that physiology for distinctively human activities and accomplishments.6Jones J.W. McCullough L.B. Futility and surgical intervention.J Vasc Surg. 2002; 35: 1305Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 7McCullough L.B. Jones J.W. Postoperative futility: a clinical algorithm for setting limits.Brit J Surg. 2001; 88: 1153-1154Crossref PubMed Scopus (28) Google Scholar The surgeon should explain to the patient's family the concept of clinical or overall futility and the clinical ethical judgment that the obligation of the surgeon and family to continue life-sustaining treatment has come to an end. The implementation of advance directives was one of the most notable practice-enhancing ethical landmarks of the last century. Many patients were sacrificed willingly on the altar of the goddess Lachesis (who held the thread of life and determined its length) thinking she could be forced to lengthen what was already cut. Now as evidenced-based medicine gains traction, we realize sometimes that “to do everything” is bad medicine.