Should We Allow Natural Death? (AND)

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After series of acute deaths following to devastating haemorrhagic strokes and ineffectiveness of sham ventilation after futile CPR, we evoked discussion about allowing natural death and make policy about “Do Not Resuscitate” order.

Indian law is silent about futility of resuscitation in terminally ill patients. There is no documented cases of negligence due to failure of cardiopulmonary resuscitation. Yet there is serious disagreement and confusion among caregivers across the Indian Hospitals.

Origin of CPR

1960s - Anesthesiologists did CPR on adults and children who suffered from witnessed cardiac arrest following reversible illnesses and injuries.

CPR became the standard of care for all etiologies of cardiopulmonary arrest and the universal presumptive consent to resuscitation evolved

Is CPR always beneficial?1974, the American Heart Association (AHA) recognized that

under certain circumstances, CPR may not offer the patient direct clinical benefit the resuscitation will not be successful or will lead to co-morbidities that will merely prolong suffering without

reversing the underlying disease. AHA Recommended that physicians document in the chart

when CPR is not indicated after obtaining patient or surrogate consent.

This documentation formally became known as the DNR order

Defining Direct Medical Benefit – Outcome of CPR

In Hospital Cardiac ArrestAdult

survival rates - 8-39% and favorable neurological

outcome in 7-14%Children

Survival rate 27% with a favorable neurological

outcome in 20%

Out of hospital Cardiac arrestAdult

7-14% and Infants and children

3-9%

When can CPR be withheld?

Futile CPR When CPR cannot reverse the on‐going dying process or Will not provide therapeutic benefits that outweigh the harms

or substantial burdens of CPRRefusal of CPR by competent adult patients

Are DNR Ethically Acceptable ?

“It is widely recognized by health care professionals, clergy, lawyers and others that DNR orders are medically and ethically appropriate under certain circumstances.”

How are DNAR Orders Written?

Prior to writing a DNAR Order, physicians should discuss resuscitation preferences with the patient or his/her surrogate decision maker 1. Why and how the initial question of resuscitation status was raised.2. Decision making process which has been and will be followed:a. Professional staff involvement;b. Role of parents and patient;c. Data upon which decision is based.3. Summary and update of planning process and decision.4. Summary of conversations with patients and parents.

If CPR is "futile," should a DNAR order be written?

“If health care providers unanimously agree that CPR would be medically futile, clinicians are not obligated to perform it.”

What if CPR is not futile, but the patient wants a DNAR order?

This position stems from respect for autonomy, and is supported by law in many states that recognize a

competent patient's right to refuse treatment.

What if the family disagrees with the DNAR order?Obtain a second opinion or transfer the patient unless

the patient’s condition precludes doing so. Clinical staff are not required to perform

physiologically futile and harmful treatments on a patient.

Review

What are CPR mimics?Slow Codes - is an act that resembles CPR yet is not the

full effort of resuscitation.Show code - is a short and vigorous resuscitation

performed to benefit the family while minimizing harm to the patient.

Comfort Care - only comfort care be administered before, during, or after the time a person’s heart or breathing stops

Comfort Care-Arrest - the use of life-saving measures (such as powerful heart or blood pressure medications) before a person’s heart or breathing stops.

Special Circumstances

ChildrenSurgical ProceduresEmergency Medical Technician

When to Discontinuation of a DNR Order?A DNR order may be revoked by a competent patient or

surrogate decision‐maker, unless it is futile or non therapeutic

Discontinuation of the DNR order must be documented

Living Will?A person of sound mind can himself instruct the doctors to withdraw life support measures. Doctors would be bound by such instructions. If they persist with such measures, they would be committing an illegality for which the patient or his LRs can sue the doctor. However, this must be properly documented with, preferably, the LRs / attendants being a witness to such instructions.A person of sound mind can also instruct those concerned in advance through a living will not to start or to withdraw life support measures. Doctors would be bound by such instructions.

Dr. M C Gupta (Former Professor and Dean)MD (Medicine), LLM

Advocate (Delhi Bar Council no. 857/2001)

Like any serious medical procedure CPR should be performed judiciously to prevent burden of morbidity and expenditure

to the caregivers . “We should Accept Natural Death”

Thanks