DNACPR

What is CPR
• A set specific medical procedures designed to establish circulation and breathing in
a patient.
• Designed to maintain perfusion to vital organs while attempts are made to restore
spontaneous breathing and cardiac rhythm by implantable cardioverter
defibrillation.
• If the patient stops breathing or cardiac arrest occurs in the hospital, then standard
care involves CPR in the absence of a valid physician’s order to withhold it.
• Hospitals have policies that describe circumstances under which CPR can be
withheld.
 Some general situations arise that justify
withholding CPR:
• When CPR is judged to be of no medical benefit
• When the patient has the capacity to make serious decisions and clearly
indicates that he or she does not want CPR, with signed documents
confirming these wishes written in medical—rather than legal—language
• When the patient displays an impaired decision making capacity, a health
care proxy can make the decisions for the patient.
• The proxy can indicate that the patient does not wish to receive CPR
 In these situations, physicians are ethically justified
in withholding resuscitation.
CPR is
futile
It is important to define what it means to “be of
when it benefit.”

offers the
patient no One approach to defining benefit examines the
probability of an intervention that leads to a
desirable outcome.
clinical
benefit. CPR has been prospectively evaluated in a wide
variety of clinical situations. Knowledge of the
probability of success with CPR could be used to
determine its futility.
 Quality of Life
• CPR might also seem to lack benefit when the patient’s quality of life is so
demonstrably poor that no meaningful improvement is expected with
resuscitation. Judging “quality of life” tempts prejudicial statements about
patients with a chronic illness or disability.
• There is substantial evidence that patients with such chronic conditions may
rate their quality of life much higher than would healthy people.
• Patients in a permanent unconscious state possess a quality of life that few
people would accept; therefore, CPR is typically considered “futile” for such
patients.
 Obligations
• If CPR is judged to be medically futile, then the health care professional has
no obligation to provide it.
• Nevertheless, the patient, his or her family members, or all parties should have
a role in the decision about a DNR order to preserve the principle of
autonomy.
• In many cases, the patient and his or her family, upon being given a caring but
frank understanding of the clinical situation, will agree with the DNR order.
• In such cases, a DNR order can be written at that time.
 DNR Order
• Each hospital should have specific procedures for writing a valid DNR order. In all
cases, the order must be written or co-signed by the attending physician.
• A decision to withhold CPR may also arise from a patient’s expressed wish that CPR not
be performed.
• If the patient understands the existing medical condition and possesses an intact
decision-making capacity, then the DNR request should be honoured.
• Ethicists and physicians are divided about how to proceed if family members disagree.
• USA- A DNR order can only be written with full agreement by the patient or family member.
• UK- Input of family considered but the decision does not lie with them.
 “Slow Codes”

So-called “slow-codes,”
Such actions undermine
where half-hearted
a patient’s rights and
efforts at resuscitation
violate the code of
are made, are not
physician–patient trust.
ethically justified.