If ED patients are resuscitated despite the existence of a valid DNR order, it is a serious ethical concern. However, this happens more often than one might believe.1 “Performing a medical intervention, such as CPR, on a patient who did not wish to be resuscitated violates a patient’s autonomy,” says Danielle Turrin, DO, assistant professor of medicine at Hofstra/Northwell in Hempstead, NY.
Of 419 cardiac arrest patients, 65 were DNR status. Of this group of DNR patients, 38 were resuscitated against their wishes. “Not adhering to a patient’s wishes not only violates their autonomy, but it is arguably not acting in the patient’s best interest — and may in fact be causing them suffering or harm,” Turrin says.
Additionally, when patients are resuscitated against their wishes, it means many other medical resources are used, such as ventilators and ICU beds. “This may make [resources] unavailable or difficult to procure for the patients who do desire them,” Turrin offers.
Unwanted CPR happened for several reasons. Some DNR orders were not documented; other valid orders were documented, but clinicians did not realize it. Certain patients had only non-actionable advance directives to convey their wishes.
“When it comes to CPR and end-of-life care, physicians should be having these difficult and sensitive conversations with patients early in the course of an illness and with any change in their health status,” Turrin emphasizes.
Physicians should ensure their patients’ wishes are documented as medical orders. “These need to be displayed or stored in a way that are easily accessible and can be honored and upheld by other medical professionals, such as EMS,” Turrin stresses.
Family members should be included so they can honor and respect their loved one’s decisions, too. “Obviously, the most concerning implications of ignoring or misunderstanding a patient’s goals of care is the irreversible lack of resuscitation or the irreversible resuscitation,” says Jay M. Brenner, MD, FACEP, medical director of the ED at Upstate University Hospital’s Community Campus in Syracuse, NY.
There also can be reversible intubations onto ventilators. In Brenner’s experience, poor agreement on goals of care between patients and ED physicians happens for these reasons:
- The patient has not defined his or her goals of care beyond “feeling better.” “Nobody has taken the time to discuss their prognosis and offer palliative care,” Brenner notes.
- The ED physician does not know the patient’s goals of care. “It is critically important that ED physicians ask patients what their goals of care are at the earliest opportunity before irreversible decisions have to be made,” Brenner stresses.
- The ED physician disagrees with the patient’s goals of care. This is uncommon, but some physicians may question the patient’s decision-making capacity to choose comfort care. In rare cases, the physician might even believe it is not best for the patient.
“The ED physician should prioritize the patient’s preferences over their own. If the patient does lack decision-making capacity, reach out to an appropriate surrogate decision-maker,” Brenner says.
- Haddad G, Li T, Turrin D, et al. A descriptive analysis of obstacles to fulfilling the end of life care goals among cardiac arrest patients. Resusc Plus 2021;8:100160.