After Texas passed a law complicating the process for issuing Do Not Resuscitate (DNR) orders, some clinicians were concerned it would adversely affect vulnerable patients hospitalized at the end of life.
“Many of our patients and families are desperately hoping to be rescued, and are experiencing intense emotions like sadness and grief. It is very difficult to find acceptance and verbalize a preference to pass with peace and dignity,” says Jason Morrow, MD, PhD, professor of medical humanities and ethics at UT Health San Antonio.
The central ethical concern is making patients express their end-of-life preferences in writing or in front of strangers is stigmatizing. This could threaten autonomy and result in CPR for patients who will not benefit. A literature search revealed lack of evidence about outcomes in this scenario. Morrow and colleagues set out to examine the possible effects of the Texas law.
The law, which took effect in 2018, did not make DNR orders illegal, but it added cumbersome requirements for documentation and witnessing. Morrow and colleagues analyzed charts of all adult patients admitted to a hospital before and after the law went into effect. They reviewed code status orders for the 5,426 sickest patients.1 Implementation of the Texas law correlated with fewer DNR orders among seriously and terminally ill patients.
“The Texas law makes DNR feel abnormal, like it’s out of the ordinary, a form of giving up or euthanasia,” Morrow says. To counter this, Morrow suggests hospitals make the signature forms or witness recruitment process “easy, friendly, and shame-free.”
“Ethicists should help their hospitals develop related protocols,” Morrow advises. “For practitioners, code status conversations should be treated with the seriousness of a surgery.”
That means involving the right people and taking the time to ensure medical understanding and prognosis, as well as patient values and goals, before talking about a plan of care. “When possible, practitioners should bring up DNR at the end of a meaningful conversation,” Morrow adds.
In Texas, doctors cannot write a DNR order unless the patient agrees to it, or the patient’s decision-maker agrees in the event the patient cannot make the decision. “The default is that the request not to be resuscitated has to come from the patient — and only if the patient is not mentally competent to make that decision does it go to an alternate designated decision-maker,” explains Michael S. Ewer, MD, JD, PhD, faculty at the University of Houston Law Center.
Ewer says physicians frequently broach the subject by saying to the patient something like, “We have run out of treatment options. As the situation gets closer to the end of your life, there will be a decision that has to be made about whether you want to be resuscitated.” In this instance, legal obligations may conflict with ethical obligations. Is it ethical to offer a meaningless resuscitation in the face of virtually certain death from incurable disease? “The law says you have to do that,” Ewer says. “Are we giving choices that might make sense in other circumstances, but don’t make sense in the face of obvious end-stage disease?”
The law requires physicians to document the conversation on DNR status took place, along with the response. Instead of this requirement, Ewer would like to see an approach where, as patients become increasingly less likely to benefit from resuscitation, a pathway can be found that maximizes the chances of recovery when possible, and minimizes the likelihood of inappropriate resuscitation in the face of obvious end-stage disease. “If we are not months before death, but a day or two or even less, an ethics group could make a decision indicating that it is ethical in this situation and that it is medically appropriate not to resuscitate,” Ewer says.
Ideally, physicians should feel comfortable writing appropriate DNR orders, knowing there is immunity from lawsuits if they follow procedure, and that they are not in violation of any ethical principles, Ewer adds.
Sometimes, physicians do not write DNR orders simply because they are uncomfortable discussing it with patients. “They feel it is their job to push the envelope as far as they can. At some level, the physician is unwilling to face the fact that there is nothing left to offer beyond comfort measures, and yet they don’t want to give up,” Ewer observes.
In some cases, patients are transferred to a tertiary center. The sending facility assumes someone at the tertiary center will address DNR status. The tertiary center staff assumes the DNR order has been discussed, the referred patient has declined resuscitation, and there is no need to rehash a difficult discussion. “As the transition to comfort measures takes place, physicians should make sure that if DNR status has not already been discussed, it should be discussed at that time,” Ewer says.
For example, physicians can say to the patient, “We’ve maximally treated you, and we can’t control the progression of your disease. We are going to now think about changing your care from how to try to make you better to how do we make sure that we don’t add to your suffering, and that you’re comfortable for the rest of the time that you have. When your body indicates that it can’t go on and it doesn’t make any sense to try to restart it, that is the time when we would say we should not undertake resuscitation because it can’t do any good.” As part of that discussion, physicians can see if the patient is open to hospice care.
As it stands now, there are many reasons why physicians do not write DNR orders, even when it is appropriate to do so. Possibly, the patient has not made up their mind about DNR status.
In some instances, no one ever asked the patient because unexpected deterioration made the conversation impossible. Sometimes, the patient asked to be DNR, but then loses decision-making capacity. Thus, the physician asks a family member if they are OK with the DNR status. This is an unethical practice, according to Ewer.
“They do that, in part, to avoid possible litigation or challenges to the decision initiated by a surviving family member who may not have agreed with the patient’s directive,” Ewer explains.
Ewer says a more ethically sound practice is for physicians to say, “You have incurable illness, and if we resuscitate you, it will only delay the moment we declare you dead.” Some patients fear once a DNR order is written, optimal care might be compromised. They may be concerned as to whether interventions, such as blood transfusions, might be modified after the DNR order is written.
“Physicians may share this concern. This is clearly an opportunity where education could play an important role,” Ewer says.
REFERENCE
1. April CW, Morrow J, April MD. Code status blues: Do legal nudges discourage doctors from ordering do-not-resuscitate? Perm J 2022 Aug 16;1-7. doi: 10.7812/TPP/22.036. [Online ahead of print].
Ethicists should help develop related protocols. For practitioners, code status conversations should be treated with the seriousness of surgery. That means involving the right people and taking the time to ensure medical understanding and prognosis, as well as patient values and goals, before talking about a care plan. When possible, practitioners should bring up DNR at the end of a meaningful conversation.
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