Physicians are evenly divided as to whether unilateral do not resuscitate (DNR) orders — decisions about resuscitation made by doctors without patient or surrogate consent — are appropriate, found a recent study.1

“The debate over this topic in the ethical literature remains unsettled,” says lead author Michael S. Putman, MD, a fellow in the department of medicine at Northwestern University in Chicago.

Some physicians argue that resuscitation efforts can, and should, be withheld if a reasonable chance of benefit does not exist. Others argue that unilateral DNR orders violate patient autonomy and lack objective criteria.

Putnam was surprised at how evenly physicians were divided on the issue, with roughly half in favor and half opposed. “It’s interesting to see such equipoise over something that many find so contentious,” he says. Some key findings of the research, which surveyed 1,156 physicians, include the following:

• physicians who endorsed unilateral orders were more likely to be in pulmonary or critical care medicine, and less likely to be religious;

• 6% of all physicians, and 20% of pulmonary critical care physicians, reported performing a unilateral DNR in the previous year.

Putman says greater attention should be paid to this topic: “Unilateral DNR orders represent one end of the spectrum of autonomy and paternalism. Their implementation should be undertaken with care.”

Unilateral DNR orders often are considered when the patient or surrogate wishes to continue treatment, but the medical team believes this would be nonbeneficial or even harmful.

“Sometimes physicians feel so compelled to act according to the principles of nonmaleficence and beneficence that they want to write a DNR order over the objection of the patient or surrogate,” says Monica Gerrek, PhD, assistant professor in the department of bioethics at Case Western Reserve University and co-director of MetroHealth System’s Center for Biomedical Ethics, both in Cleveland.

Unilateral DNRs should be implemented as a last step, after all other options have been exhausted, says Cheyn Onarecker, MD, MA, chair of the healthcare ethics council at Trinity International University’s Center for Bioethics & Human Dignity in Deerfield, IL.

“In the not-too-distant past, families were concerned that physicians were keeping their loved ones on life support too long,” says Onarecker. The opposite scenario is more common now, with families worried that the medical team is withdrawing life support too soon.

“Physicians can become frustrated trying to help a family come to a reasonable decision,” says Onarecker. “They might enter a DNR order to shut down a very challenging dispute.”

Physicians are usually reluctant to order unilateral DNRs. This is due to potential legal consequences and perceived ethical obligations to honor surrogate preferences regarding resuscitation in all circumstances. “The current model of decision-making for DNRs gives significant ethical weight to the patient’s autonomy,” says Adam Pena, MA, an instructor at Baylor College of Medicine’s Center for Medical Ethics and Health Policy and a clinical ethicist at Texas Medical Center, both in Houston.

On the other hand, an obligation to attempt resuscitation in the absence of clinical indications for CPR may compromise the clinician’s professional integrity. If the patient is imminently dying, says Pena, “the provider’s medical judgment about whether or not there are medical indications for CPR is a major ethical consideration.”

Conflict over unilateral DNRs often arises within a larger context, says Pena. There often is conflict between the reality of the prognosis and what the surrogate understands the situation to be. A poorly informed surrogate might have no idea why the unilateral DNR is being requested. “If a conflict arises in real time, ethicists could help clarify the reasoning behind the request for a unilateral DNR, and help the team and family achieve consensus,” suggests Pena.

Typically, the family, or a single family member, wants maximum treatment to continue, and the medical team is asking to limit or withdraw maximum treatment. “These situations usually bring up the concept of futility, a word that sometimes muddies the water because it has been used in many ways,” says Onarecker.

Providers may use “futility” to refer to treatments that simply will not work — for instance, administering penicillin to a person dying from an infection that is resistant to penicillin. “No physician is required to offer this sort of futile treatment,” says Onarecker. “But futility is also used to describe treatments that have only a small chance of success, maybe 1 in 100. The surgeon might think of such a treatment as futile, but the family might think that 1 in 100 is better than no chance at all.”

Other times, “futility” is used to describe a situation where the patient’s ultimate quality of life will be poor even if the best possible outcome occurs from an intervention. “You might hear a comment like, ‘That’s not how I would want to live.’ But that is a value judgment and not really a medical decision,” says Onarecker. Quality of life decisions must be made in light of what the patient, not the clinician, would find acceptable.

Families sometimes worry that a DNR order means their loved one won’t continue to receive excellent care. Once a decision has been made to limit treatment, the patient might be moved out of the ICU to a floor with less monitoring and fewer nurse visits. “To the family, it could look like the patient is being abandoned,” says Onarecker. “It is important to remember that DNR means that the patient will not receive CPR, but other treatments could still be continued.”

The medical team must reassure the family that certain treatments will be stopped, but compassionate care always will be given. “Ethicists can facilitate open discussion, ensure that that everyone’s voice is heard, and help all parties come to a reasonable solution,” says Onarecker.

An institutional policy can encourage consistent decision-making by outlining criteria for when a unilateral DNR order may be appropriate. “The champion for this policy will need to establish institutional and administrative buy-in,” says Pena.

It seems that physicians often feel that, without a DNR order, they are obligated to provide medical treatments or CPR — even if they believe it will do more harm than good.

“A good unilateral DNR policy can assist in these situations,” says Gerrek.

She says that the policy should ensure that all possible avenues for conflict resolution — ethics, palliative care, chaplaincy, social work, and psychology — have been exhausted, and outline a process for resolution if a medical team member is strongly opposed to the unilateral DNR order, as follows:

1. Ensure the surrogate/family fully understand the nature of the patient’s medical situation.

2. Try to determine what might be influencing the surrogate/family’s position.

3. Offer a second opinion.

4. Request a palliative care consult.

5. Request a chaplaincy consult. “Chaplains are very good at assisting with psychosocial or spiritual issues that may be influencing the surrogate/family,” says Gerrek.

6. Request an ethics consult:

• offer for the team to assist in facilitating a transfer to another institution;

• include options for the patient or surrogate to pursue if they disagree with the order.

For example, a policy should allow time for patients or surrogates to find institutions willing to provide treatment or seek legal recourse. “While good policies are important and necessary, good conversations in advance of a crisis are even more important,” says Gerrek.

This means in-depth discussions between patients, surrogates, and physicians about treatment options and goals of care.

“Furthermore, there needs to be a culture change in the way Americans think about treatment at the end of life,” says Gerrek. Studies show that people often want to die at home, yet most die in a medical institution. Studies also show that surrogates often lack good understanding of patient wishes.2,3

“It stands to reason that if patient wishes were better known by the physician and surrogate, the need for unilateral DNR orders would decrease — as would conflicts between the surrogate and team,” says Gerrek.

In many states, there is no law supporting unilateral DNR orders. “In fact, in some states, the patient or surrogate has the right to revoke a DNR order,” says Gerrek. This means that physicians are faced not only with overriding the wishes of the patient or surrogate, but also with whether to act in a way that could lead to legal conflict.

“Yet, without the option of a unilateral DNR order, physicians often do not have a way of communicating to other team members that they do not believe CPR or other life-sustaining interventions are appropriate,” says Gerrek.

Physicians’ litigation fears sometimes are groundless. This is why it’s important to understand relevant state laws. “There is a variance in the legal landscape regarding unilateral DNRs,” notes Pena.

States that do offer guidance allow unilateral DNRs in limited circumstances.4 Texas’s 1999 Advance Directives Act allows physicians to withdraw life-sustaining treatment unilaterally, but only after an extensive process is followed. A Texas physician may write a unilateral DNR only in circumstances where 1) the physician has certified in writing that the patient has a terminal and/or irreversible condition; 2) when, after diligent inquiry, a surrogate has not been identified; and 3) when a second physician not directly involved in the patient’s treatment concurs with the attending physician’s medical judgment.5

“In my experience, physicians may be hesitant to write the DNR order because it is unclear what constitutes a ‘diligent inquiry,’” says Pena. Physicians are unclear on what exact measures are required to try to identify an appropriate surrogate.

In Vermont, assuming a surrogate is not available to make medical decisions, two clinicians must determine that resuscitation “would not prevent the imminent death of the patient.”6 “Here, is it unclear what the law means by ‘imminent death,’” says Pena. Further complicating matters, studies have demonstrated that physician prognostication of a patient’s imminent death often is inaccurate.7

While some states require multiple-step processes — second opinions, legal input, and extensive participation by the ethics committee — others offer no legal guidance at all. “Therefore, hospital policy may be the appropriate mechanism to govern these unilateral DNR decisions,” says Pena.

REFERENCES

1. Putman MS, D’Allessandro A, Curlin FA, et al. Unilateral do not resuscitate orders: Physician attitudes and practices. Chest 2017; 152(1):224-225.

2. Shalowitz DI, Garrett-Mayer E, Wendler D. The accuracy of surrogate decision makers: A systematic review. Arch Intern Med 2006; 166(5):493-497.

3. Fagerlin A, Ditto PH, Danks JH, et al. Projections in surrogate decisions about life-sustaining medical treatments. Health Psychol 2001; 20(3):166-175.

4. Pope TM. Medical futility statutes: no safe harbor to unilaterally refuse life-sustaining treatment. Tennessee Law Review 2007; 71(1):1-81.

5. Texas Advance Directive Act § 166.039. Available at: http://bit.ly/1dcBUL5. Accessed Jan. 10, 2018.

6. 2012 Vermont Statutes Title 18 Health Chapter 231 § 9709 Obligations of health care providers, health care facilities, residential care facilities, and health insurers regarding protocols and nondiscrimination 18 V.S.A. §9709. Available at: http://bit.ly/2CMDtPo. Accessed Jan. 10, 2018.

7. White N, Reid F, Harris A, et al. A systematic review of predictions of survival in palliative care: How accurate are clinicians and who are the experts? PLoS One 2016;11(8):e0161407.

SOURCES

Monica Gerrek, PhD, Co-Director, Center for Biomedical Ethics, MetroHealth System, Cleveland. Phone: (216) 778-7290. Email: mlg86@case.edu.

Cheyn Onarecker, MD, MA, Chair, Healthcare Ethics Council, The Center for Bioethics & Human Dignity, Trinity International University, Deerfield, IL. Phone: (405) 272-7494. Email: cheyn.onarecker@ssmhealth.com.

Adam Pena, MA, Instructor, Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston. Phone: (713) 441-4925. Email: adam.pena@bcm.edu.

Michael S. Putman, MD, Department of Medicine, Northwestern University, Chicago. Phone: (312) 695-1510. Email: msputman@gmail.com.