Your Doctor Has a DNR Order, But Not for the Reasons You’d Think

by Jacob Dahlke, Bioethics Program Alum (MSBioethics 2012)

How many doctors would choose to have a “Do-Not Resuscitate” (DNR) order over a full code option? 88.3%, at least according to a new study. For those counting at home, that’s greater than percentage of Americans who currently disapprove of the job that Congress is doing.

This means that nearly 9 out of every ten physicians would not personally choose the treatment that they routinely perform on their elderly, frail, critically ill, or emergent patients. (There is some concern that these patients are not routinely provided an effective mechansim for making this decision, meaning the default treatment in most cases is to provide CPR regardless of underlying conditions; perhaps that’s a topic for another post.)

This is an intriguing figure, one that on its face seems to imply that physicians may be providing treatments that they know they ought not; after all, if they don’t choose it for themselves, then certainly it is not an effective treatment. Perhaps there is an alternative view, however. Before I discuss this modified perspective, let’s first get into CPR a bit more.

First, CPR refers to cardiopulmonary resuscitation, or an attempt to restart a person’s heart that has stopped beating. This loss of function means that there is no blood (and thus no oxygen) pumping through the body, meaning that a person will not have a pulse if checked. The subsequent lack of oxygen to the brain leads to death. Second, where you receive the CPR attempt can determine it success. Only 1 out of 8 persons who suffer cardiac arrest outside of a hospital survive. It initially appears that survival is higher in a hospital setting: 38% of patients over the age of 70 who received CPR had a return of blood circulation.

This statistic alone can be misleading, however, since over half of those patients (the ones who received CPR) don’t survive until being discharged from the hospital. If we reorganize the definition of success based around patient goals – surviving until getting out of a hospital, or not dying in a hospital – then that number drops to 12%-18% (based on age). CPR may provide an additional 24 hours, albeit in a hospital. So this is, in a conservative estimate, a potential reason that physicians decide against this treatment for themselves.

But the tone in such news articles seems to suggest that physicians have some sort of secret that they are holding against their patients. Instead, it could be a lack of access to relevant information, and a lack of education on the part of the patient to make informed decisions at this juncture of their lives. A physician who becomes a patient is simply in a better position to be informed about the risks, benefits, and alternatives to any proposed treatment, including CPR. To expect that a ‘typical’ (non-medically trained) patient would have the same level of knowledge is inaccurate.

Instead, by presuming that a patient does not know what they don’t know, then there becomes a responsibility to ensure that a patient understands their clinical situation. So the physician, at age 72, would opt out of attempts at CPR because s/he knows that there is only an 18% chance of survival and recovery. For the other patient, s/he may choose to remain full code, believing that nearly 1 in 5 is a good enough chance to ‘go for it’. Or not. But the medical community must do a better job of communicating relevant information about end-of-life treatments and options.

To advocate for more, and better, discussions about CPR, DNR, and code status is not to advocate for wresting control away from patients and limiting their lives. It is instead empowering them to make better, more informed decisions about treatments that align with their personal values.

[This blog entry was originally posted in a slightly different form on Mr. Dahlke’s blog on May 30, 2014. Its contents are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

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