Do-Not-Resuscitate Depressed Psychiatric

Linda Ganzini, M.D. Melinda A. Lee, M.D.

Ronald T. Heintz, M.D.

Orders for Inpatients

deaths, and unless CPR is specifically proscribed, it is routinely performed on dying patients in hospitals. CPR is attempted in about one-third of the 2 million patient deaths that occur in U.S. hospitals each year (5). The indiscniminant use of CPR has been challenged in the last ten years. Recent studies have demonstrated that CPR is futile for many elderly patients with chronic medical illnesses (4,6-8). For these patients, CPR is not deemed life saving but death prolonging (9). Results from patient surveys in many settings indicate that CPR and mechanical ventilation are not desired by all patients. A study of258 elderly outpatients reported that only 36percent desired both CPR and mechanical ventilation in the case of cardiac arrest (10). A study in Great Britain found that 47 percent of mentally competent elderly inpatients did not want resuscitation (1 1). Among residents of long-termcare facilities, between 38 and 90 percent reported that they did not want CPR (12,13). There is an ethical and legal consensus that mentally competent patients have a right to refuse life-sustaming therapy, including CPR. Guidelines of the American Medical Association state that the physician has an ethical obligation to honor the resuscitation preferences expressed by the patient (5). The right to refuse life-sustaining treatment, inc!uding CPR, was recently reaffirmed by the U.S. Supreme Court in Cruzanv. Director(14).

Joseph

D. Bloom,

M.D.

Patients and their families need accurate information about the risks and benefits of CPR and about the consequences of refusing the procedure. In recent decades, medical progress has made it possible to sustain life through a variety of technological means, such as cardiopulmonary resuscitation (CPR) and advanced cardiac life support. However, many patients choose to forgo CPR in the case ofcardiac arrest. On medical inpatient services, determination of patients resuscitation preferences is now commonplace. Psychiatrists increasingly care for patients who are physically as well as mentally ill. The number ofaged patients has increased, and psychiatnists now treat many elderly patients with chronic and debilitating medical illnesses on inpatient psychiatnic units (1,2). For some patients the question of resuscitation status arises. In this paper we discuss considerations in determining the resuscitation status of psychiatric inpatients and the role of advance directives in communicating patients preferences about resuscitation. We present three case vignettes that posed dilemmas about the use of donot-resuscitate orders for depressed, elderly psychiatric inpatients.

Many patients, especially those who are elderly and who have chronic medical illnesses, cbvxse to f orgo cardiopulmonary resuscitation (CPR) in case of cardiac arrest. The right ofmentally competent patients to refuse CPR is supported k ethicists, the courts, and medical associations. Psychiatrists are increasingly presented with dikmmas about resuscitation preferences ofelderly psychiatric inpatients whose decision-making capacity may be impaired because of mental illness such as depression. The authors discuss justifications f orpatients refusing resuscitation, the role of advance directives in communicating patients preferences, and the use of do-not-resuscitate ordersfor depressed psychiatric inpatients. Survival rates after CPR among elderly patients with chronic medical illnesses are low.

Dr. Ganzini
psychiatry

is director

and

geriatrician fairs Medical

of geriatric Lee is a staff at the Veterans AfCenter (1 16A-P),

Dr.

P.O. Box
97207. Dr.

1034,

Portland,
is also

Oregon
assis-

Ganzini

tant

professor Oregon Health

of psychiatry at Sciences Univer-

Justification
forgoing

for

CPR

sity, where Dr. Lee is assistant professor of medicine, Dr. Heintz is adjunct assistant professor of

psychiatry, and Dr. Bloom is professor and chair of the department of psychiatry. Dr. Heintz is also supervising psychiatrist at Dammasch (Ore.) State Hospital.

developed in the 1 960s for treatment of cardiac arrest in otherwise healthy victims of acute medical illness (3). Since that time, the use of CPR has expanded, becoming a mandate for all patients who experience cardiac arrest regardless of their underlying disease processes (4). Cardiac arrest precedes all

CPR was originally

Determining patient preference

In hospitals and long-term-cane institutions, a mentally competent patient may request that no CPR be performed should he or she have a

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cardiac arrest. Based on an informed consent model, the patient must be able to understand the nature of CPR and advanced cardiac life support, its risks and benefits, the alternatives, and the consequences of refusing the procedure. The patient must be free to choose whether to consent to or refuse the proposed treatment (15,16). A competent patients informed decision is communicated through a donot-resuscitate order recorded by the physician in the medical record (5). Because mental status changes are often part ofthe dying process, many patients have diminished ability to express a reasoned, authentic preference for or against CPR at the time when its need is imminent. In the Cruzan decision (14), the Supreme Count supported use of written advance directives, such as a living will or a durable power of attorney for health care, to ensure that patients preferences are communicated for future episodes ofdecisional incapacity. Living wills, in general, instruct the physician to withhold treatments such as CPR if the patient has a terminal illness-that is, less than one year ofexpected life (17). They are of limited usefulness because with many disease processes the length of remaining life cannot be predicted with certainty. A durable power of attorney for health care, now available in 17 states, allows a competent patient to assign decision-making responsibility for health cane decisions to a surrogate (18). The sunrogacy becomes effective only if the patient is either temporarily or permanently incapacitated. In 1988 living wills had been cxecuted by only 1 5 percent of Amenicans, and fewer than 3 percent had executed a durable power of attorney for health care (19). To facilitate the use of advance directives, in 1990 Congress passed the Patient Self-Dctermination Act (20). This regulation was implemented in December 1991 and requires all hospitals (inc!uding psychiatric hospitals) that receive Medicare or Medicaid to provide written information to all adult patients on their rights under state law to make decisions about their medical cane, including the right to accept or refuse care and the right to

formulate an advance directive. The information must also include institutional policies for implementing these nights. The Patient Self-Determination Act also requires hospitals to inquire whether a patient has executed an advance directive such as a living will or a durable power of attorney for health care. The patients response must be documented. The law nequires hospitals to ensure compliance with advance directives consistent with state law and to avoid discnimination on the basis of whether the patient has executed an advance directive or not. Hospitals must educate staffabout advance directives. Do-not-resuscitate decisions

for

depressed

patients

Psychiatrists in general hospitals are increasingly confronted with questions about the resuscitation status of psychiatric inpatients. The Joint Commission on Accreditation of Healthcare Organizations requires all psychiatric hospitals to have donot-resuscitate policies (2). In many types of psychiatric inpatient settings, advance directives are part of patients permanent hospital record, and thus patients preferences are evident to a!! physicians who care for them. Patients may be transferred from medical wards to psychiatric inpatient units with do-not-resuscitate orders already recorded. The Patient Self-Determination Act encourages patients to bring their preferences about resuscitation to their psychiatrists attention. However, psychiatrists may not be as comfortable with patients nesuscitation preferences as their mcdical counterparts are. Do-not-resuscitate orders on inpatient psychiatric units may be considered unnecessary and premature by psychiatrists because dying patients are transferred to medical services. Discussions of resuscitation preferences may be viewed as countertherapeutic because they may increase some patients anxiety or hopelessness. Psychiatnists may perceive a conflict between honoring a do-not-resuscitate request and preventing refusals of care associated with suicidal ideation (2). Because patients ability to rcason may be impaired, psychiatrists

may believe that their duty to protect patients from decisions with potentially irrevocable consequences is paramount. Depression may impair the capacity to make treatment decisions by promoting irrational treatment refusals by patients who are hopeless, mistrustful, apathetic, or suicidal. Hopelessness on delusions associated with depression may cause the patient to underestimate the benefit of treatment. Impaired self-worth or fear of being a burden to others may result in treatment refusal. Depression may also be associated with apathy, ambivalence, and indecision such that the patient has difficulty expressing a choice or prematurely abdicates decision making to a family member or a health cane provider. Refusal of CPR or requests for donot-resuscitate status may represent a desire to die and to end the suffering associated with depression (21). In the psychotically depressed patient, refusal oflife-sustaining procedunes such as CPR may be fueled by paranoid delusions about the procedure on mistrust of medical personnd. Ambivalence associated with depression or psychosis may impair the ability to maintain and communidate a stable choice (22). Thus patients with severe emotiona! distress who require psychiatnc hospitalization are encouraged to defer major life decisions until their mental status improves. Although patients with depression are cared for in other hospital settings, nonpsychiatnic physicians may view determination of decision-making capacity more narrowly by giving primary consideration to a patients understanding of risks and benefits, without clearly addressing the role of affective disturbances or mistrust in the patients decision (23,24). Implementation of the Patient Self-Determination Act will encourage patients to make known their preferences about treatment at the end of!ife. The law gives strong support for physician compliance with patients wishes. Psychiatrists concern for patients nights may conflict with their concern for patients wellbeing.

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Ethical

dilemmas:

case vignettes The following cases illustrate some dilemmas we have encountered in determining resuscitation status of depressed psychiatric inpatients. The patients in these cases were treated voluntarily on a universityaffiliated psychiatric inpatient unit. The first two cases came to our attention during a research study investigating the effect of treatment for depression on patients decisions about life-sustaining interventions. Case 3 was brought to our attention by psychiatrists who were aware of our interest in this area. Case 1 . An elderly, cognitively intact woman was admitted to a general hospital psychiatric unit for treatment of severe depression. She agreed to participate in a survey about the effects ofdepression on decision-making about life-sustaining interventions. She was told that the answers to her questions were confidential and nonbinding and would neither be recorded in hen chart nor revealed to her health care providers. She was told that all depressed patients her age on the unit were asked to participate. Despite these reassurances, she began to weep after several questions by the interviewer, saying, You are asking me these questions because you believe these things are going to happen to me, dont you? This case illustrates a major concern ofpsychiatrists in determining patients preferences for CPR: such discussions may frighten depressed patients, reinforce their beliefs that providers consider the situation hopeless, and interfere with the therapeutic process of nemoralization. Studies have found that between 13 and 32 percent of general medical outpatients do not want to discuss their resuscitation preferences (9,25, 26). In one study from which depressed patients were excluded, discussion ofpreferences regarding lifesustaining procedures caused negative emotions in a significant percentage ofpatients; 22 percent felt nervous, and 16 percent felt sad (26). Although it is recommended that physicians determine patients resuscitation preferences well in advance

of need, routine discussion of resuscitation with all patients at the time of admission to a psychiatric inpatient unit may not be appropriate and is not required by the Patient Self-Determination Act. More nesearch is needed about the impact on depressed psychiatric inpatients of routine physician-initiated do-notresuscitate discussions. Case 2. A 78-year-old cognitively intact woman, who had recently undengone a resection of a lung tumor, was admitted for treatment of depression to a university psychiatric unit. She explained that she had signed a living will that was on file with her primary physician, who was affiliated with the same hospital. She also had completed a durable power ofattorney for health care, designating a friend as her agent in case of futune incapacity. The patient and the friend reported that both documents were executed before the episode of depression. On admission to the psychiatric unit, the patient requested do-notresuscitate status. Her friend stated that this desire was consistent with the patients wishes before the onset of her depressive episode. The attending psychiatrist said he felt obligated to refuse hen request; to record hen do-not-resuscitate status in the medical record would be to possibly participate in hen murder. He believed that should she require

CPR,

she had a 60-percent

chance

of

being alive and functionally mdcpendeni in three months. Although the psychiatrist accurately defined a do-not-resuscitate order as meaning that in case the patient suffered cardiac arrest, no CPR would be performed, he also expressed concerns that access to intensive care and other life-sustaining treatments would be withheld. In this case, the issue of deciding resuscitation status when a patient is depressed was further complicated by the existence of two written advance directives that have statutory protection. The psychiatrist in this scenario was placed in a dilemma. The patients agent, designated to make health care decisions for her during episodes of decisional incapacity, may not have recognized

incipient depression as a factor in the patients desire to forgo life-saving interventions. Alternatively, the desire to forgo resuscitation may have preceded depression, and thus any resuscitation attempts would violate her rights. Further exploration of the patients state of mind at the time she talked about these matters, their relationship to the onset of depression, and the stability of her preferences over months to years may have helped the psychiatrist resolve his doubts about the authenticity of her request. However, although he legitimately questioned the dccision-making capacity of the patient at the time she completed the documents, in general, physicians are bound to follow an advance directive. A physician may refuse to honor a do-not-resuscitate request because of religious or philosophical beliefs about the sanctity oflife. The Patient Self-Determination Act does not override state laws that allow for health care providers, as a matter of conscience, to refuse to implement an advance directive. In those cases, the provider must inform the patient of his or her belief and transfer the patient to another provider. Ifa physician questions the validity of the advance directive because of suspected patient incompetence at the time it was executed, he or she must petition the count to have it rescinded (1 8). Some states protect medical personnel from liability for refusing to honor an advance directive. Other states specify sanctions for failure to follow a directive. Sanctions range from a misdemeanor offense through civilliability and revocation of the medical license (27). This case also demonstrates that inaccurate knowledge of the risks and benefits of CPR may promote reluctance to honor a do-not-resuscitate request. For example, the paychiatnist in this case was reluctant to record the patients resuscitation preference because he overestimated the success rate ofCPR. After CPR is attempted, only 1 5 to 1 7 percent of all patients survive until discharge (9). Among elderly patients with chronic medical illnesses who suffer an in-hospital cardiac arrest, the out-

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come is uniformly poor; from 0 to 4 percent survive until discharge from the hospital (6,8,13). In one study of 294 patients who underwent resuscitation procedures, no patient with metastatic cancer, pneumonia, sepsis, or acute stroke survived until discharge (28). Outcomes are better (14 to 30 percent survive until discharge) in healthier, younger populations who suffer ventricular fibrillation (9). In addition to being overly optimistic about the patients prognosis, the psychiatrist hesitated because he incorrectly believed that a do-not-resusci tate order limited other treatment options such as treatment in an intensive care unit. Decisions to forgo CPR can occur contemporaneously with decisions to withdraw and limit other treatments . However, a do-not-resuscitate order prohibits only the use of

CPR and does not communicate

any

other limitations oftreatment (5,9). Case 3. A 65-year-old man was admitted to a psychiatric inpatient service for treatment of depression and refusal to take food, medications, and fluids. As a result of several strokes, he had hemiparesis, dysphagia, and decreased visual acuity, but he was otherwise cognitively intact. Both he and his wife requested that no extraordinary measures be taken should he become more ill, and on further discussion with the family a do-not-resuscitate order was written. Because he had not previously expressed a preference for donot-resuscitate status, and because he had a history of refusing food as a result of family discord, his treatment plan included daily discussions with him to verify the stability of his preference for do-not-resuscitate status. Over the next week, as he was asked, Would you like your heart started again should it stop beating ? his do-not-resuscitate order was written and rescinded four times. After a week in the hospital, he permanently rescinded the order, accepted a feeding tube, and began to participate in therapies. The mental health providers documented that the patients wife continued to disagree with the resuscitation status

throughout the remainder of the patients hospitalization. The mental health team caring for the patient understood the dilemma of balancing the patients right to self-determination with their concern that his depression heavily influenced his request for do-notresuscitate status. The treatment plan ofasking him every day to consent to or reject CPR perhaps increased the patients ambivalence, with deleterious effect. This degree of instability of preference indicates substantial impairment in decisionmaking capacity (21). Advising the patient and family that recording the do-not-resuscitate status in the mcdical record should be temporarily deferred would have been appnopniate; however, ongoing discussions are necessary until a stable preference is elicited. Webb and Amchin (2) pointed out that unnco!ved disagreements about do-not-resuscitate orders may contribute to deterionation of the therapeutic alliance between the psychiatrist and the patient and family. The providers in this case could be faulted for not giving the patient accurate information about the nature ofthis procedure and its benefits. Lo (9) warned against phrasing that suggests CPR is as simple and effective as jump-starting an automobile or changing a fuse. The physician should provide an explanation of the nature ofCPR, including chest compressions, electrical shock, and intubation, in an explicit manner. The possible outcomes should be clanfled, including the likelihood both of success and ofadvense outcomes such as death and irreversible coma. When a patient is incapacitated, many agree that family members become the most appropriate decision makers because they are are the most knowledgeable about the patients values and preferences (16). In some states it is lawful for physicians, without a court proceeding, to obtam consent from the patients relatives to withhold treatment from a terminally ill patient (29). Surrogate decision makers, whether or not they are legally entitled through a durable power of attorney for health cane or guardianship, should be instructed

to choose what they believe the patient would choose, if competent, based on previously expressed wishes and known values and beliefs. Of concern are studies that show that spouses predictions are no more accurate than chance alone in predicting what patients would want in hypothetical scenarios ofiliness (10). Cases in which the surrogate knowingly recommends actions that are not consistent with the patients desires are rare, but the physician must be alert to the possibility. Physicians are not obligated to comply with requests by legally designated surrogates if the physician believes that there is a conflict of interest on that the surrogate is acting in bad faith (18,30). Hospital ethics committees can be an important source of guidance and mediation in dilemmas about do-not-resuscitate orders and advance directives. Their role is most often advisory, but they can help clarify the patients best interest and provide support for the parties involved in making these difficult decisions (12,31). Ifinstitutional mcdiation fails to resolve a conflict between a surrogate decision maker and a physician, it is appropriate to seek the assistance ofthe court (18). Conclusions Psychiatrists care for many patients, including frail elderly nursing home residents, AIDS patients, and olden adults with chronic mental illness. Decisions about the resuscitation status of such patients cannot be postponed forever. Psychiatrists cannot abdicate their responsibilities in this area. CPR is a treatment that is routinely administered without the patients consent because informed refusal is required in order to forgo this procedure. But as one author writes, All too often CPR just happens without inquiry into the paticnts wishes or consideration of its chances ofsuccess (4). Requests by depressed psychiatric inpatients to forgo resuscitation present a clinical dilemma for psychiatnists. The desire to forgo CPR may result from depression. However, the fact that many patients without mental disorders but with chronic debilitating medical condi-

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tions do not desire interventions such as CPR cannot be overlooked. Depression should not mandate CPR, nor should it invalidate all decisions about the manner ofones inevitable death. The following guidelines are suggested pending further research on the effect of depression on patients decisions about life-susraining interventions. If, in the psychiatrists estimation, the patients decision-making capacity is unaffected by depression (or another mental disorder), requests to forgo CPR should be respected and recorded in the medical record. If the psychiatrist believes that depression is impairing the patients decision-making capacity, ancillary information should be sought. If a durable power of attorney for health care exists, the assigned agent should become the surrogate decisionmaker. If there is no such document, the patients family and primary physician should be questioned about the patients previous wishes and state ofmind when the preferences were discussed. Ifthe patient has previously stated clear wishes regarding resuscitation, those wishes should be honored. Consultation with medical colleagues may assist in determining the benefits of resuscitation. Futile medical therapy need not be pursued. In addition, ifthe patient has a living will and the medical colleague assesses that the patient has a tenminal illness, do-not-resuscitate status should be recorded. Deferral ofa decision is appropniate if the patients decision-making capacity is impaired because of depnession, a legally designated sunrogate decision maker is unavailable, the patients previous wishes are not clearly known, and therapy is not futile. In such a case, discussions with the patient should continue until a stable, informed, authentic preference is elicited. In some cases, consultation with the hospital ethics committee or legal counsel is appropniate. The Patient Self-Determination Act encourages patients to initiate discussions with their physicians about preferences regarding life-sustaming therapies such as CPR. Psy-

chiarnists need to increase their knowledge of advance directives and develop a new level of sophistication in the use ofdo-not-resuscitate orders. Acknowledgments This work was partly supported by the Medical Research Foundation of Oregon. The authors thank Jackie Lockwood for assistance in manuscript preparation.

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