Walk through almost any medical intensive care unit in the country and you will encounter patients with terminal diseases who received CPR despite having had no chance of meaningful recovery from their conditions.
Alarmed at this situation, a group of end-of-life specialists wants to transform how physicians approach the issue of resuscitating severely ill patients. In an era of misused medical technology and rising health care costs, especially at the end of life, we should listen.
An article, which appears in the March 7, 2012 issue of the Journal of the American Medical Association, proposes giving physicians more authority in restricting cardiopulmonary resuscitation (CPR) from patients they do not believe would benefit.
"Do Not Resuscitate" (DNR) laws are one of the successes of the bioethics movement, which replaced the traditional model of physician-dominated paternalism with an emphasis on patients' rights. In 1987, New York became the first state to pass a DNR law, which stipulated that CPR would be performed unless a patient or a patient's family (in cases of incapacity) formally declined it. The law came in response to newspaper articles revealing that physicians were playing God, deciding amongst themselves which patients should or should not receive CPR.
DNR laws in New York and elsewhere have been highly successful, enabling patients and families to weigh both medical prognosis and personal values when making decisions. Patients with identical medical conditions may genuinely have different opinions about whether or not their hearts should be restarted.
But the pendulum, which was once too far on the side of the physicians, has now swung too far in favor of patients, according to Columbia University Medical Center palliative care expert Dr. Craig D. Blinderman and his colleagues. In the JAMA article, they cite data suggesting that patients and family members wrongly assume that being offered CPR means it is the "correct" choice. We are left, the authors argue, with an "ethically unjustifiable situation wherein many patients are exposed to significant harms with little or no benefit."
Blinderman and his team propose a three-pronged approach to DNR discussions, which would vary based on the potential benefits and harms of CPR in given situations. The first scenario would resemble what is currently done for all cases: "Consider CPR as a plausible option." In this situation, patients who might benefit from CPR should be given information about their illness and prognosis, emphasizing what is known in the medical literature about the likely value of CPR in such cases. Physicians would then abide by the choices reached by patients, or if appropriate, families.
The second scenario is where things would begin to change. The JAMA article argues that in cases when the likelihood of harm from CPR is much greater than the likely benefits, physicians should recommend against CPR -- that is, push hard for DNR status. There are good data, for example, that suggests that 90 to 95 percent of patients with advanced dementia or metastatic cancer do not benefit from CPR performed in hospitals. If they even survive their cardiac arrests, they are likely to wind up with severe neurological damage or dying in intensive care units. The authors would permit CPR among such patients, however, if it is "grounded in the patient's values and goals" and there is potential for a "modicum of medical benefit."
The third scenario is the medical profession's version of "just say no," which means not offering CPR. This decision would apply when patients not only have terminal disease, but are also so ill that even with CPR, they would die imminently without any chance of leaving the hospital. Such a policy, which Blinderman and colleagues encourage individual hospitals to draft in conjunction with experts in ethics, palliative care and the law, would turn the current system on its head for a select group of patients. Patients and families would be informed of the mandatory DNR decisions and offered support services.
Any efforts by the medical profession to curb patient autonomy deserve strict scrutiny lest we return to the unfortunate era of paternalism. And it will not be easy to effect these types of changes. Legal cases in which physicians have tried to cease treatment in so-called futile cases have generally resulted in victories for families.
But it really is time for a change. We do not offer surgery to patients expected to die in the operating room. We do not continue to transfuse patients with bleeding that cannot be stopped. We do not give new organs to people who request them if they will not benefit. What is going on in many of our intensive care units is shameful and violates the physician's oath to "do no harm."
Moreover, health care costs continue to rise, now consuming over 17 percent of the GNP. Roughly 25 percent of Medicare funding is spent during the last year of life. Proven preventive health measures, such as cancer screening, remain underfunded.
What we have learned from decades of patient autonomy is that well-meaning decision-makers sometimes need help from experts who know the medical literature. Let's carefully begin the process of making DNR decisions more like other medical decisions.
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