Even if an ED patient’s do not resuscitate (DNR) status is well-documented, family members may demand resuscitation — sometimes vehemently.

“Allowing for family to dictate the care of a patient against the patient’s wishes is a violation of the patient’s dignity,” says Jay M. Brenner, MD, FACEP, associate professor in the department of emergency medicine at State University of New York, Upstate Medical University in Syracuse.

If a clinician performs an intervention on a patient against his or her clearly stated wishes, adds Brenner, it may be perceived as an assault. “If a clinician does not attempt resuscitation in spite of a surrogate decision-maker’s objections to honoring a patient’s wishes, then the clinician is fulfilling a promise made to the patient from the healthcare system,” adds Brenner.

It’s not uncommon for distraught family members to threaten to sue the clinician refusing to attempt resuscitation. “But as long as the clinician has clear evidence of the patient’s wishes, then the clinician is safe from a malpractice accusation,” says Brenner.

Violence against healthcare providers always is a possibility, depending on the family’s ability to cope with the clinician’s interpretation of the patient’s decision. “The clinician should be prepared with security measures,” says Brenner.

A difficult scenario is when the surrogate decision-maker says that he or she would like to disregard a DNR order because he or she believes that it is best, yet the patient’s documentation is not available. “Electronic MOLST [Medical Orders for Life-Sustaining Treatment] forms, or an equivalent, can avoid the situation where the clinician does not have access to the DNR form,” says Brenner.

When conflicts arise over an ED patient’s DNR status, Brenner uses the following approaches:

• sitting down at the same level as family, regardless of the heightened anxiety surrounding the situation;

• use of scripted, yet personalized, phrases, such as, “I am trying to do what your loved one (fill in relationship or name) would have wanted;”

• involving social workers and chaplains to help alleviate the family’s stress.

Recently, a wife asked clinicians to disregard her husband’s preferences because she couldn’t bear to see him go. “When her adult children arrived soon after, they were able to persuade her to allow me to honor his wishes,” says Brenner.

In another case, two sons both claimed to be healthcare proxy. They did not agree on whether their mother would have wanted to be put on a ventilator. It became clear that the son who wanted the ventilator was basing the choice on what he thought was best. “The other brother was able to persuade him to base his recommendation on what their mother would have wanted,” says Brenner.

Verified DNR orders should be followed in the ED unless the patient has stated wishes to the contrary, says Catherine A. Marco, MD, FACEP, professor in the department of emergency medicine at Wright State University in Ohio.

However, many patients present to EDs with terminal conditions without any advance care planning whatsoever. “In these cases, it may be appropriate for the emergency physician to work directly with the patient, family, and treating physicians to determine the prognosis and the patient’s goals of therapy,” says Marco. In some cases, a DNR order is instituted in the ED, provided it clearly is the patient’s wish.

A formal ethics consultation may be helpful in cases in which the patient’s wishes are unclear, but it’s challenging in the ED setting. “This often takes some time and may require inpatient consultation,” says Marco. “I have never personally used an ethics consultation in the ED, because of the timeliness issue.”

At times, the patient is unresponsive or otherwise unable to participate in medical decision-making. “If there is disagreement with family wishes and a pre-existing advance directive, state law should be followed,” says Marco. “Many states confer immunity for healthcare providers who follow an approved advance directive.”

It’s possible that a surrogate decision-maker presents convincing evidence that a patient changed his or her mind about DNR status. In this case, says Brenner, the clinician’s decision to attempt resuscitation is ethically justified.

The patient might have had a recent conversation with the surrogate after a change in health status. “If the surrogate decision-maker’s statement is based on the patient’s wishes, then it ought to be followed,” says Brenner. “If it is based on what the surrogate decision-maker thinks is best, then the patient’s expressed wish ought to be followed, provided that the form is valid.”

If the clinician suspects that the surrogate decision-maker is acting maliciously — for example, prolonging a relative’s life for the sake of collecting Social Security checks — then the clinician should potentially invalidate the role and seek another surrogate decision-maker, says Brenner.

“In absence of a surrogate decision-maker, then clinicians ought to follow the patient’s stated wishes on a valid MOLST form,” says Brenner. “Without a surrogate decision-maker or a MOLST, the clinician should attempt resuscitation.”

SOURCES

• Jay M. Brenner, MD, FACEP, Associate Professor, Department of Emergency Medicine, State University of New York, Upstate Medical University, Syracuse. Email: brennerj@upstate.edu.

• Catherine A. Marco, MD, FACEP, Professor, Department of Emergency Medicine, Wright State University, Ohio. Phone: (937) 395-8839. E-mail: catherine.marco@wright.edu.