Pulling the Plug on DNR

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Recently, a friend commented that she was not sure whether or not to agree to a “DNR order” for her 90 year-old mother. Her mother has dementia and lives in a nursing home; she is her mom’s health care proxy. Complicating her decision was the knowledge that her mother had chosen a DNR status when she was cognitively intact, but then reversed her decision at the time of acute illness, believing that “DNR” meant she would not receive vigorous treatment for medical problems such as an infection or congestive heart failure. My friend told me she believed the purpose of a DNR order was to avoid a protracted, painful death and that DNR was synonymous with comfort care. 

The truth is that DNR means “do not perform CPR”—the “R” in DNR refers to resuscitation, which is shorthand for “cardiopulmonary resuscitation.” CPR is a procedure intended to counteract a cardiac arrest—the sudden cessation of the heart beat and of breathing. CPR involves administering electric shocks and, more often than not, providing artificial respiration, usually through a breathing machine (ventilator). In principle, DNR or, as it should more properly be called, since there is only a small chance that CPR will actually succeed in restoring cardiac function, DNAR (do not attempt resuscitation) refers only to what will or will not be done if the heart stops beating and breathing ceases. It has no implication for any other form of treatment. But nearly 40 years after the first DNR orders were written in hospitals, confusion about their meaning persists.

It’s not just patients and families who are confused: physicians are confused as well. I just read Sheri Fink’s book, Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital, in which the triage decisions made during Hurricane Katrina included placing patients with a DNR order at the bottom of the evacuation list. Reportedly, physicians at Memorial thought that patients could have a DNR order only if they were terminally ill, which is false: a patient can elect a DNR order whenever the burdens of CPR are felt to outweigh the benefits, or if CPR is thought to be extremely unlikely to succeed–regardless of the underlying medical condition. When it looked as though not all of Memorial Hospital’s patients were going to be evacuated, it was the DNR cases who were to be left behind, sedated so as to ease their allegedly inevitable and imminent deaths.

And it’s not just in the midst of a disaster that physicians mistake “DNR” for “Do Not Treat.” Study after study has shown that physicians say they would not administer a whole variety of treatments to patients who are DNR. One representative study of 241 physicians found that they were far less likely to agree to transfer a patient to the intensive care unit or even to perform simple tests such as drawing blood. 

Most recently, physicians and nurses caring for pediatric patients also told interviewers that in practice, DNR means far more than just do not perform CPR. In this survey of 107 pediatricians and 159 pediatric nurses in a hospital setting, 67% believed a DNR order only applies to what to do after a cardiac arrest—but 33% said it implied other limitations. And 52% said that once a DNR order is in place,  a whole host of diagnostic and therapeutic interventions should be withdrawn, over and beyond CPR, and a small but disturbing minority, 6%, said that a DNR order means that comfort measures only are to be provided. 

Why, so many years after the concept of DNR was introduced, does it remain so problematic? I think both patients and physicians implicitly recognize that asking about CPR is simply the wrong question—that’s why they assume DNR refers to so much more than what doctors should do if the heart stops beating. The right question has to do with figuring out what it is that medical treatment is supposed to achieve. Is it prolonging life at any cost? Is it providing comfort and dignity? Or is it something in between, preserving those basic functions such as walking and talking and seeing and hearing that a person values most? Only after defining the overall goal of care does it make sense to focus on delineating the specific treatments that are most consistent with achieving those goals. 

An enormous amount of energy and ink have been squandered on debating about cardiopulmonary resuscitation, one of many possible medical treatments that seeks to achieve one of several possible medical goals. Maybe it’s time to pull the plug on DNR orders, banning them unless there is first a conversation about the overall direction of medical care. 

One approach to doing exactly this is POLST, Physician Orders for Life-Sustaining Treatment or, as it is called in some states, Medical Orders for the Scope of Treatment. This is a medical order, just like an order a doctor writes in a hospital for antibiotics or for blood tests; it is not just a wish statement about future care. It includes a list of specific interventions that a prospective patient has agreed are undesirable under any circumstances, and often includes CPR along with other treatments such as dialysis or artificial nutrition. But before a physician and patient agree on such an order, a conversation is supposed to take place about the goals of medical care. The problem is that it’s far from clear that patients and doctors are having those discussions. They may simply be jumping to the final step, writing that order. POLST is a promising development, but only if at least as much time is spent on talking about the big picture as on its implementation.

 Dr. Muriel Gillick, who will qualify for Medicare in three years, is a geriatrician and palliative care physician, and a professor in the Department of Population Medicine at Harvard Medical School. She has written four books for a general audience discussing ethical, medical, and other issues arising in old age, most recently “The Denial of Aging: Perpetual Youth, Eternal Life, and Other Dangerous Fantasies” (Cambridge, MA: Harvard University Press, 2006). She blogs at Life in the End Zone, where this post was initially published.

4 Responses to “Pulling the Plug on DNR”

  1. Carol Eblen

    Thank you, Dr. Gillick, for your comments on DNR Code Status (DNR) and for stating clearly that DNR Code Status has been problematic for 40 years for physicians, hospitals, and patients. Certainly, DNRs have been misused and misapplied by hospitals/physicians these past ten years or more because of Administrative Reimbursement Protocols of Medicare/private insurance and OMB that deny and/or reduce reimbursement to hospitals/physicians because of non beneficial over treatment, exceeding Diagnosis Related Group Caps (DRG Caps). mistakes, errors, and the complications thereof.

    This presents a great problem for elderly/disabled Medicare/Medicaid patients who are often the victims of an adverse event and in a hostile environment but don’t know it and are not made aware by either the Hospital or Medicare/Medicaid that they are actually charity patients for their local hospitals.

    The policy of Medicare/Medicaid who receive public funds from the people’s Medicare/Medicaid purse to NOT reimburse for adverse events was first suggested in 2002 by the National Quality Forum (NQF) and The Leapfrog Group. These two groups “questioned why federal and state governments —through Medicare and Medicaid —would ever reimburse a hospital that permitted these “preventable: events to occur.” (See Article ” The Never Event” in publication of Pro Assurance Key Considerations for Health Care Organizations, Vol. 2, No. 2, 2009.)

    I agree with your assessment that it may be the time to BAN DNR orders because they are misused and misapplied unless there is a conversation about “overall direction of treatment.” But, of course, shouldn’t this conversation be witnessed and bear the signature of witnesses and the physician and the patient/surrogate before DNR code status is placed in the patient’s Hospital Chart? Patients or their surrogates have to sign permission to the hospital for all of the treatments that they receive within the hospital yet the patient doesn’t have to sign consent to the DNR Code Status. As one victim of a unilateral DNR imposed on his father that hastened his father’s death has observed. “Patients have to sign to get an oil change for their cars but they don’t have to sign consent for DNRs that can be unilaterally and covertly placed in their medical charts and shorten their lives without their informed consent.”

    Why not? Is this an innocent mistake or is this lack of any procedural protection against covert/overt(default) DNR Code Status intentional hospital policy that permits hospitals to misuse and misapply DNR Code Status to protect their bottom lines when “medical futility” cannot be invoked under some due-process procedure approved by the state —and when reimbursement is denied to the Hospitals for adverse events?

    In 2006, there were 26 Adverse Events (Preventable Events that should never happen) that are NOT reimbursed by Medicare/Medicaid and the private insurers who provide gap policies or who deliver Medicare benefits to patients under contract with the Medicare, i.e. the Advantage Insurers. How many more adverse events are there in 2014 and for how long have reimbursements been denied under Medicare/Medicaid Insurance for non beneficial over treatments and the complications thereof and for exceeding the DRG caps?

    Certainly, as a Geriatrician, you know that the problem for the elderly/disabled on Medicare/Medicaid since 1991 when the Patient Self Determination Act (PSDA) became law is that treating specialist physicians in the outpatient setting have NOT been seeking informed consent for Medicare Curative care and aggressive chemo, radiation, and surgery as opposed to Medicare Hospice/palliative care from elderly/disabled and often frail and senile Medicare/Medicaid patients because for-profit physicians and clinics weren’t subject to the provisions of the 1991 PSDA.

    Because physicians and private for-profit clinics and practices were not placed under the provisions of the 1991 PSDA, they have been enabled to over treat the elderly/disabled to include the elderly senile patients up to the Diagnosis Related Group Cap for the disease/cancer being treated. Some of the patients over treated for the profit motive since 1991 have been frail and senile, haven’t they? And, of course, unilateral DNRs can be used to keep these patients out of the hospital altogether when they are placed in Observation status and out of ICU and CCU if they are admitted to the hospital.

    We see now that The US Department of Justice and the Health and Human Services for the first time in 2013 have joined together to prosecute a few cancer specialists for cruel over treatment of patients for the profit motive. They are using the federal false claims act to file criminal charges against these physicians.

    This prosecution and the IPAB which will be implemented under the ACA if it is not destroyed by the Republicans will eventually stop the over treatment of the elderly/disabled on Medicare/Medicaid that has been driven by the profit motive. Individual physicians will lose their autonomy to treat Medicare/Medicare patients and will have to surrender to Big Data and Academic Prognostics and actuarial tables that will “qualify” Medicare/Medicaid patients for aggressive treatment or palliative and comfort care under the Medicare/Medicaid entitlement programs.

    But! won’t this be a fairer kind of rationing that the under-the-radar rationing of life-saving and life-extending technologies that is NOW targeting the elderly/disabled on Medicare/Medicaid and that has been targeting the elderly/disabled and the poor on Medicare/Medicaid the past ten or fifteen years?

    In the meantime, however, why wouldn’t The Hastings Center actively call for a BAN on the undercover rationing of treatments with the use of unilateral covert/overt(default) DNR Code Status that hastens the deaths of competent patients on Medicare/Medicaid without their informed consent.

    Isn’t this involuntary euthanasia in violation of federal and state law and doesn’t The Hastings Center bear some responsibility for NEVER pointing out the very real connection of “medical futility” to the hard reality of “fiscal futility” for the hospitals who take a “calculated risk” when they treat elderly/disabled patients on Medicare/Medicaid who are more prone to suffer from adverse events than younger patients?

    While the ethicists condemn the unilateral covert and overt(default) DNR code status as an ethics violation, you must be aware that the law surrounding the unilateral DNR remains unclear, and this is why physicians/hospitals feel safe to ask for forgiveness AFTER the DNR has been implemented, rather than to ask for permission for the cost-efficient DNR before it is placed in the hospital chart.

    Please read the excellent paper by Thaddeus M. Pope, the foremost historian and expert on Medical Futility and the Law, entitled “Involuntary Passive Euthanasia in US Courts” written in 2012 and available in a Google Search. This paper reveals why the cost-effective unilateral DNR imposed by the Hospital is not as problem for the Hospital or the physician. Also, there is no private right of action granted under the PSDA and the hospitals know they are protected from private lawsuits for unilateral DNRs and from criminal prosecution, as well. They assume the Courts will never look at the covert rationing by means of the unilateral DNR that is primarily a means of protecting the hospitals’ bottom lines.

    Also, the NCI has spent 4.5 billion dollars a year for cancer research these past three years that comes out of the people’s taxes and the DOD and the Centers for Disease Control and private organizations also spend many millions of dollars MORE on Cancer Research each year. Huge profits are engendered for Big Medicine and Big Drug Companies in the for-profit sector of the health care industry and in the Academic Institutions supported by public funds.

    Isn’t it incongruent or inappropriate or something? that billions of dollars are taken out of the pockets of the taxpayers to find a cure for cancer that will extend life expectancy and YET it is the elderly and the disabled and the poor on Medicare and Medicaid who are living longer who are covertly targeted with unilateral DNRs for end-of-life cost constraints?

    Is it really necessary to encourage and invite passive euthanasia of the elderly, disabled, and the poor to achieve the fiscal goals of Medicare to save Medicare and to protect the profit margins of Big Insurance and Big Medicine?

    I look forward to your further comments on my questions and concerns. Thank you for your grace and kindness —-for talking to me.

    .

  2. Carol Eblen

    We are talking about two different systems here! The Medicare/Social Security/Medicaid programs that provide the safety net for the elderly, disabled, and poor through taxes AND the for-private health care system that serves the balance of the American people under age 65.

    It is because private for-profit Big Insurance and Big Medicine and Big Pharmacy invaded the original Medicare program that we have the problems we have today.

    This particular problem of unilateral DNRs is a direct reaction to reimbursement protocols of CMS that are influenced by private BIG Insurance.

    How could Big Insurance continue to sell Medicare GAP policies and Advantage policies at a profit unless original Medicare were convinced to reduce/refuse reimbursements to the subscribers by way of reimbursement protocols like “adverse” events, non-beneficial over treatment, exceeding the Diagnosis Related Group Caps, etc..

    Congress did mandate that private Insurance companies provide at LEAST as much as original Medicare when they sold “Advantage” policies so, of course, original Medicare now provides less under Medicare law in order to ensure the profits of Big Insurance.

    Nothing wrong with the administration of the huge Social Security System by the government, is there?

  3. Carolyn winfield

    I am sadly but personally affected by this injustice to the poor, black, disabled, elderly and seriously ill daughter’s medically care was covertly and overtly deemed “futile” at the UCH and their “unilateral for” was cited to turn off my daughter’s pacemaker/ ICD without her or her family’s knowledge, consent, informed Consent or due process of law. I have medical records to back up everything that I am saying here. My PRO SE, YES PRO SE complaint is now in the Illinois Supreme Court 13L2636, 142100.MURDER of the sick is the easiest to get away with especially if you are black, poor, disabled and elderly. BLACK LIVES OF THE SICK MATTER TOO..Thank You for your time and HELP if you can.