Cases & Commentaries

The Wrongful Resuscitation

Commentary By Joan M. Teno, MD, MS

The Case

An 80-year-old man with diabetes, peripheral
vascular disease, bilateral below-the-knee amputations, and poor
quality of life had previously been resuscitated from sudden death.
After his recovery, he completed a DNR (do not resuscitate) form
signifying his desire to avoid such treatment in the future.

The patient presented to the emergency department
(ED) in extreme pain and was found to have a ruptured abdominal
aortic aneurysm (AAA). Although his DNR form was with him, neither
the ED staff nor the consulting surgeon looked at it. The patient
was rushed to the operating room (OR), where his AAA was repaired.
Postoperatively, an internist came upon the DNR form in the
patient's chart and discussed resuscitation preferences with the
patient and the family. The patient reconfirmed his desire to avoid
resuscitation and heroic procedures, expressing anger that he had
been taken to the OR for the AAA repair. The family agreed with the
patient's choice. The internist wrote a DNR order in the chart, but
the surgeon—having just completed major surgery on this
patient—was furious, changing the code status back to "full
code." Ultimately, the internist consulted with the hospital
ethicist, who convinced the surgeon to honor the patient's and
family's wishes. The DNR order was reinstated, and the patient
later died of a cardiac arrest during the hospitalization.

The Commentary

The fear of older, dying persons having life
prolonged against their wishes has in part driven the current focus
on completing written advance directives in the United States. This
focus may be somewhat surprising, because the published evidence
indicates that patients being resuscitated against their wishes is
a rare event. In a review of 17 narratives from the Study to
Understand Prognoses and Preferences for Risks of Treatments
(SUPPORT), there were no cases in which a physician unilaterally
ignored patient preferences to provide life-sustaining
treatment.(1) At
least in SUPPORT, the predominant concern was the converse: that
physicians did not write a Do Not Resuscitate (DNR) order in nearly
1 in 2 cases when there was evidence (based on patient or family
member interview) of that patient's preference to forgo
resuscitation.(2) Although this failure to document a
DNR preference is concerning, the absence of a DNR order did not
result in resuscitation being performed against a person's wishes
in SUPPORT.(3)
Moreover, a 1995 study found that only 26% of hospitalized nursing
home residents who had previously executed an advance directive had
these preferences recognized during that hospitalization. However,
when the advanced directives were recognized, they influenced
treatment decisions in 86% of cases.(4) Thus, "near misses" do not frequently
translate into cases where a patient is wrongfully
resuscitated.

Although the rarity of the error of physicians
"trumping" or ignoring a patient preference by mistake is somewhat
reassuring, there do appear to be many cases in which patients are
at risk of receiving treatment inconsistent with their previously
stated wishes, and patients seem to harbor significant concerns
regarding the lack of communication.

While case reports of physicians unilaterally
trumping patient preferences exist, as the surgeon did in this case
by reversing the DNR order against a patient's preferences,
fortunately they are rare. In this example, an ethics committee was
utilized to resolve the conflict with a surgeon who was
unilaterally making a decision against a patient's informed wishes.
An ethics committee is an appropriate vehicle to help resolve these
conflicts. It should be noted that the case as presented does not
question the authenticity of the patient's decision to complete a
DNR order. Indeed, the patient signed a DNR order in the nursing
home, and the family agreed with the patient's wishes and decision.
This leads to a very important question regarding the actions of
the surgeon. Should that physician be sanctioned for making a
decision that flagrantly ignored a patient's preference? I believe
that such behavior should receive the same scrutiny as operating on
the wrong side of the brain—each is a bodily assault that
provides harmful care to which the patient did not consent. Such a
case should be reported to the appropriate state authorities, and
the resulting sanctions and corrective actions should ensure that
informed preferences by future patients are honored.

Although the actions of the surgeon in this
case raise important concerns, two other issues in this case also
deserve greater discussion. A critically ill nursing home resident
is transferred to the ED with severe abdominal pain and
hypotension. In the midst of crisis, the physician did not realize
that the patient was DNR and successfully resuscitated this elderly
patient. This is an important error. Transitions of care involving
frail, older persons are often problematic. The error of
resuscitating a patient because health care providers were unaware
of his code status reflects inadequate communication and
coordination of care between the nursing home and the ED. Steps can
be undertaken to prevent this error, including the
following:

  • The use of a bracelet identifying the
    patient’s DNR status is increasingly being adopted by states
    to ensure that patients are not resuscitated against their wishes
    by emergency medical services (EMS) staff and other health care
    providers. The majority of states have adopted an out-of-hospital
    DNR policy. Physicians being aware of their state law and following
    the state protocol for out-of-hospital DNR orders are critical
    steps to ensure that patient preferences are honored.(5)
  • When a frail, older nursing home
    resident is transferred to an acute care setting, not only should
    an interagency form be completed, but a verbal report should be
    called to the ED. Each ED must develop a system that ensures that
    information from that verbal report becomes part of that
    patient’s treatment record. Electronic medical records can
    include appropriate "flags" that make sure that important
    information such as DNR orders and drug allergies is immediately
    accessible to treating physicians. The primary care physician
    should follow up with a phone call 24 hours after admission to
    review the patient’s care and ensure that the treating team
    at the hospital has all the information needed to ensure continuity
    of the care plan.

The second issue, which may not seem like an
obvious error, reflects one of the predominant concerns with
decision making at the close of life. Too often, the timing of
discussions to clarify patient preferences only occurs in the last
days of life. As the previously cited data illustrate, the error of
"wrongful" resuscitation is exceedingly rare. Rather, the more
common error occurs when the physician has not written a DNR order
because the patient's end-of-life wishes have not been clarified.
It is this delayed communication that can lead to higher health
care costs and higher utilization of the intensive care unit (ICU)
for the seriously ill.(6) For the frail, older nursing home
resident, the discussion of CPR is somewhat of a moot point given
the poor outcomes of resuscitation. Murphy and colleagues
(7) found that
residents age 70 and older are resuscitated successfully in fewer
than 1 in 100 cases, matching a threshold that has been proposed
for a treatment to be deemed "futile." In this 80-year-old man with
multiple organ impairment, the most appropriate focus of advance
care planning should have been on the role of the acute care
hospital. If the physician and nursing home staff addressed the
appropriate use of hospitalization and prospectively discussed the
goals of care with the patient and family, I strongly suspect that
the high costs of terminal hospitalization could have been
avoided.

Increasingly, nursing homes are utilizing "Do
Not Hospitalize (DNH) Unless for Comfort" orders in frail, older
nursing home residents. In 2000, nearly 1 in 10 nursing home
residents with advanced dementia had a DNH order.(8) The frequency of such
orders varied substantially across the United States, ranging from
0.7% in Oklahoma to 25.9% in Rhode Island. Regions with higher
rates of DNH orders for persons with advanced dementia had fewer
patients admitted to the ICU during a terminal hospitalization. In
cases like this one, clarifying patient preferences regarding the
use of the acute care hospital in the nursing home setting is an
important way to prevent inappropriate terminal hospitalizations.
Too often, the question asked about the use of life-sustaining
treatment is, "Do you want me to resuscitate your mother?" or "If
she gets sick, should we send her to the hospital?" Rather, health
care providers need to be trained in a goal-based approach to
advance care planning in the nursing home setting.(9,10) There are three key steps in
this approach.(10)

First, listen to the patient
and family. A key step in advance care planning is to listen and
understand where the patient and the family are in living with
multiple chronic illnesses. Has the patient reached a point where
continued existence is burdensome? Does the patient have
preferences that should help guide his or her treatment
decisions?

Second, based on understanding where the
patient is in his or her disease trajectory, the health care
provider should clarify misconceptions, state what they
heard the patient and/or family tell them
about where they
are in the disease process, and formulate goals of
care.
For example, "Given what you have told Mrs. Smith,
your goal is to focus on your comfort, not interventions that would
prolong your life." For the nursing home resident, typical goals
could include treatment to focus on extending life regardless of
their current state of health or efforts to restore them to their
current state of health. However, if that is not possible, care
should focus on comfort even if it shortens life. Such a focus on
comfort may lead to a decision to forego further
hospitalizations.

Third, working with the nursing home staff,
the physician formulates a care plan that ensures that
those goals are met.
Often, this includes a referral to
hospice that will work with the staff in the nursing home to
formulate a plan for palliation of symptoms and avoiding
hospitalization against the wishes of the nursing home residents
and/or family.

Increasingly,
decisions regarding medical care for frail, older persons involve
making choices that involve a trade off between quality and
quantity of life. Eliciting and respecting an informed patient's
preferences are key to making this decision. Communication needs to
occur early in the disease course. A 3-step goal-based approach to
advance care planning listens to where the patient is in living
with multiple chronic illnesses, formulates goals of care, and then
develops a plan of care that outlines how those preferences will be
honored. Key parts of this plan include taking steps to ensure that
the goals of care are communicated across settings of care and
considering whether transfers from setting to setting (including
nursing home to hospital) are appropriate in the first
place.

Take-Home Points

  • A physician unilaterally trumping an
    informed patient's choice should be treated as a sentinel
    event.
  • Good communication (including telephone
    calls from the primary care physician to the ED staff and the
    admitting physician 24 hours after admission) is important to
    ensure continuity of information about a patient’s advance
    care plans and medical condition.
  • Physicians should be familiar with the
    out-of-hospital DNR laws in their state and counsel patients to
    wear the appropriate bracelet or other means of signifying that the
    patient is DNR as prescribed by state law.
  • For frail, older nursing home residents,
    a key point of clarification as part of advance care planning
    surrounds the role of hospitalization. Such clarification may
    result in the use of a "Do Not Hospitalize Unless for Comfort"
    order.

Joan M. Teno, MD, MS
Professor of Community Health and Medicine
The Warren Alpert School of Medicine at Brown University
Associate Medical Director, Home and Hospice Care of Rhode
Island

References

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Feeding Tube Insertion Among Persons with Advanced Cognitive
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3. A controlled trial to improve care for
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