AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. January 2005, Volume 7, Number 1.

Module 5

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Case 5.3: Withdrawing or Withholding Treatment—Respecting Patients' End-of-Life Decisions

Related topic: DNR orders

Cessation of cardiac or respiratory function will be an inevitable part of Mrs. Scott's dying process; accordingly, CPR could be used prior to her death. Two sets of circumstances indicate that CPR should not be used in this and similar cases.

First, as previously discussed, patients have the right to refuse medical treatment, even when such a refusal is likely to result in serious injury or death. Mrs. Scott, therefore, may express in advance her preference that CPR be withheld in the event of cardiac arrest. Such a refusal serves as the basis for a do-not-resuscitate order. DNR orders, at least in theory, permit patients to express their preferences regarding the use of life-prolonging treatment while they still have decision-making capacity.

Second, CPR should not be used when an attempt to resuscitate the patient would be futile in the judgment of the health care team. A physician is not ethically obligated to make a specific diagnostic or therapeutic procedure available to a patient, even upon specific request, if the use of such a procedure would be futile (see also Case I of this module). Specifically, futility in this case and others like it would be the inability to restore pulmonary or respiratory function.

Opinion 2.20, "Do-Not-Resuscitate Orders"

...Patients at risk of cardiac or respiratory failure should be encouraged to express in advance their preferences regarding the use of CPR, and this should be documented in the patient's medical record. These discussions should include a description of the procedures encompassed by CPR and, when possible, should occur in an outpatient setting when general treatment preferences are discussed or as early as possible during hospitalization...Physicians should not permit their personal value judgments about quality of life to obstruct the implementation of a patient's preferences regarding the use of CPR...

DNR orders only preclude resuscitative efforts in the event of cardiopulmonary arrest and should not influence other therapeutic interventions that may be appropriate for the patient.

In practice, physicians and patients alike may find it difficult to engage in discussions about the possibility of patient death, particularly in the early stages of hospitalization. However, as the need for such a discussion becomes urgent, the patient no longer may be capable of participating in the decision-making process. An absence of patient involvement may result in mistaken impressions about the medical procedures employed during resuscitation efforts and the probable outcome of CPR, or may result in the implementation of decisions that are not in accord with the patient's values and preferences. There is a good deal of evidence that Mrs. Scott would not want to be resuscitated, but this conclusion would be presumptuous on the part of the medical staff without direct discussion of a DNR.

In some cases, the successful application of CPR has been gauged by criteria that relate to the length of patient survival. Such criteria include, for example, survival for at least 24 hours following initial resuscitation, survival until discharge from the hospital, and survival for some other timeframe. Using any of these definitions of successful treatment, CPR is judged to be futile if it is unlikely to prolong the life of the patient for the period of time set forth in the criteria. This interpretation of futility is inconsistent with the principle of patient autonomy, which requires that patients be permitted to choose from among available treatment alternatives that are appropriate for their condition, particularly when such choices are likely to be influenced by personal values and priorities.

Judgments of futility that involve value judgments are appropriate only if the patient is the one to determine what is or is not of benefit among reasonable treatment alternatives, in keeping with his or her personal values and priorities. Patients, therefore, should be encouraged to discuss the expected benefits and objectives of medical treatment with their physicians and to engage in an ongoing dialogue regarding the potential for achieving these goals.

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