Physicians usually perform CPR on hospitalized patients unless there is a written Do Not Resuscitate (DNR) order. “Because CPR is the default treatment for cardiorespiratory arrest, it inverts the usual informed consent process, which requires a patient’s voluntary consent before an invasive treatment is given,” says James L. Bernat, MD, emeritus professor of neurology at Dartmouth’s Geisel School of Medicine.
Outcome data inform the potential success of CPR performed on seriously ill hospitalized patients who suffer a cardiorespiratory arrest. “When robust data show a vanishingly small likelihood of successful CPR in these cases, generally, physicians and nurses advise against attempting CPR because it would be futile in such cases,” Bernat explains.
In some hospitals, physicians managing these cases are authorized to write unilateral DNR orders without even discussing the matter with the patient. “These unilateral orders are justified by the ethical rule that physicians are not required to offer ineffective therapy to patients,” Bernat notes.
The concept of “informed assent” was developed to satisfy both the right of physicians to initiate DNR orders in futile situations and their duty to communicate to patients and lawful surrogates of incapacitated patients. With informed assent, physicians state they will write a DNR order because it would be futile and harmful to the patient to attempt CPR in their current serious illness. “A principal virtue of the informed assent approach is that it transfers the burden of decision-making from the surrogate or family member to the physician,” Bernat says.
By physicians asserting a DNR is the correct order and explaining they will write the order in the absence of objection, it alleviates the guilt family members might feel if they alone had to make the DNR decision.
Recently, a group of researchers concluded informed assent is a “feasible and reasonable” approach for some patients.1 “We wanted to work on shifting the paradigm on this issue, especially among older patients with severe underlying illness who are extremely unlikely to benefit from this procedure,” explains lead study author Renee D. Stapleton, MD, PhD, a pulmonologist and critical care physician at the University of Vermont Medical Center.
Outcomes after in-hospital CPR have not appreciably changed in the past 50 years, Stapleton notes. Outcomes are especially poor in patients with advanced underlying chronic disease. Yet, CPR has become the automatic default unless patients specifically opt out. “This opt-out approach may result in patients receiving therapies that they don’t want, and being tremendously burdened by the poor health outcomes among CPR survivors,” Stapleton says.
In contrast, the informed assent approach preserves patient and family autonomy. “It removes the burden of decision-making for a procedure that is highly unlikely to provide benefit,” Stapleton says.
Stapleton and colleagues conducted focus groups at multiple sites. Participants included patients with malignancy or advanced COPD, along with their family members and physicians. Most of participants said the informed assent approach was acceptable. Within two weeks, more participants in the intervention group than a control group had changed their code status from full code to DNR. “Preliminary implications are that the intervention is feasible and results in short-term changes in treatment preferences,” Stapleton concludes.
The existence of CPR and DNR orders “have changed the dynamic of traditional informed consent,” according to Thomas D. Harter, PhD, director of the department of bioethics and humanities and chair of the IRB at Wisconsin-based Gundersen Health System.
For all medical procedures or interventions except CPR, patients must give their permission to receive treatment. CPR is the one medical intervention for which the default is to provide treatment unless patients say they do not want it. “With DNR orders, patients give medical providers permission not to touch them,” Harter explains. While DNR orders aim to specify only what should happen to patients during cardiac arrest, everyone eventually experiences irreversible cardiac failure. “This leads to some people viewing DNR orders as extensions of the dying process — and, subsequently, considering DNR orders as contrary to the goals of full treatment,” Harter says.
Some clinicians extrapolate DNR orders to mean a person only wants comfort-focused treatments, regardless of whether the patient qualifies for (or would want) other more aggressive interventions. Because of the unique nature of CPR as an opt-out rather than opt-in treatment, patients come to expect they will automatically undergo CPR unless they give permission not to receive it. “Ethically, this seems ‘off’ from how we think about all other treatment interventions,” Harter shares.
For other treatments, it is the physician’s responsibility to decide whether a patient is a good candidate for an intervention, rather than assume the patient is automatically entitled to a treatment unless the patient (or surrogate) elects to forgo the treatment. Harter offers this example: If a cardiac surgeon evaluates a patient for a bypass surgery and determines the patient is not a good candidate for the procedure, the surgeon is not obligated to offer it. That is the case no matter how badly the patient wants the surgery. In contrast, it is customary for patients or their families to demand CPR over the medical objection of physicians.
“It has been my experience that the acceptance of informed assent regarding CPR lies mostly in how the conversation occurs,” Harter says.
If providers bluntly state CPR will not be performed, it sets up an adversarial relationship. Patients are far more receptive if the conversation begins with a reassurance. For example, providers can state, “All treatments that are effective and working are, and will continue to be, provided in alignment with the patient’s wishes.”
Then, providers can briefly explain why the patient is not a good candidate for CPR. Providers can finish the conversation by stating, “We want to focus on the medical treatment that we think might work to help your loved one, and stay away from the treatments we think won’t work or might hurt them more than help them. Because of that and what I’ve told you about CPR, CPR is not going to be offered.”
“Lastly, though, it’s important to end with a reassurance that if the patient’s medical status improves, the attending team will reconsider whether or not to offer CPR,” Harter adds.
REFERENCE
1. Stapleton RD, Ford DW, Sterba KR, et al. Evolution of investigating informed assent discussions about CPR in seriously ill patients. J Pain Symptom Manage 2022;63:e621-e632.
This concept was developed to satisfy the right of physicians to initiate DNR orders in futile situations and their duty to communicate to patients and lawful surrogates. Through informed assent, physicians state they will write a DNR order because it would be futile and harmful to the patient to attempt CPR in their current serious illness.
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