National Ethics Teleconference

*Do Not Resuscitate Policy Revision: Controversial Topics*

March 27, 2002

**INTRODUCTION**

**Dr. Berkowitz:**

By sponsoring this series of Ethics Hotline Calls, the VHA National
Center for Ethics provides an opportunity for regular education and open
discussion of important VHA ethics issues. Each call features a
presentation on an interesting ethics topic followed by an open,
moderated discussion of that topic. After the discussion we reserve the
last few minutes of each call for our 'From the Field' section, this
will be your opportunity to speak up and let us know what's on your mind
regarding ethics-related topics other than the main focus of today's
call.

One quick announcement before we get started. We have had numerous
requests to provide continuing education credit for participation in the
Ethics Hotline Calls. At present we cannot offer continuing education
credits (CEUs), but we are working with the Employee Education System to
try to overcome the significant barriers to offering CEUs for this type
of activity. In the meantime, we encourage you to work with your local
education office to make sure this activity gets entered into your
appropriate local system, for example TEMPO, so that you can capture
these education hours toward your Network Director Performance Measures.

As we proceed with today's discussion on controversial topics in the VHA
Do Not Resuscitate (DNR) Policy revision, I would like to briefly review
the overall ground rules for the Ethics Hotline Calls. We do our best to
start on time. We ask that when you talk you please begin by telling us
your name, location and title so that we can continue to get to know
each other better. As the operator asked, we request that you minimize
background noise by using the MUTE button and please do not put the call
on hold as automated recordings often come on and are very disruptive to
the call. Due to the interactive nature of the call and the fact that at
times we deal with sensitive issues, we think it is important to make
two brief final points. First, it is not the specific role of the
National Center for Ethics to report policy violations. However, please
remember that there are many participants on the line. You are speaking
in an open forum and ultimately, you are responsible for your own words.
Please remember that these hotline calls are not an appropriate place to
discuss specific cases or confidential information. Therefore, if during
the discussion we hear people providing such information, we may
interrupt and ask them to make their comments more general.

**PRESENTATION**

**Dr. Berkowitz:**

Now we can proceed to today's discussion of the revision process for
VHA's policy on do not resuscitate protocols. Our policy in this area is
complex and must achieve a balance between the relevant ethical, legal
and medical considerations. To start today's discussion, I would like to
head out to Washington DC and turn to Kate Stockhausen. Kate is a policy
analyst with our Center, and she will review the revision process that
current VHA DNR policy is undergoing. Kate, are you there?

**Kate Stockhausen:**

Yes, thanks Ken. Before I review the revision process for the DNR
policy, I want to update everyone on the revision of the Informed
Consent Procedures handbook, which is 1004.1. The revised handbook is
due to enter the concurrence process in the very near future, and we
really appreciate all the comments we have received on various drafts of
the revised policy. Keep an eye out for the new informed consent policy
soon!

Current VHA policy on Do Not Resuscitate protocols, which is M-2, Part
I, Chapter 30, was written in 1994. The National Center for Ethics began
the formal review of the current policy in February of this year. We
circulated the policy widely throughout VHA with a request for feedback
on how to revise it. We also requested that people make suggestions on
whether we should rewrite the DNR policy to address other end of life
issues, for example terminal sedation, that are not adequately addressed
in other VHA policies such as the Informed Consent Procedure handbook or
the policy on Advanced Care Planning. We received over 40 comments on
how to review the current DNR policy. A working group will be convened
in mid-April to consider the comments and brainstorm on how best to
revise the policy. A draft will be written that will be considered by
Center staff and working group members. A further draft will then be
developed and this will be distributed to the field for comments. Now,
just as a side note, we would like to remind everyone in the field that
local DNR policies must be consistent with the current national policy,
and while it is not our role at the Center to enforce compliance with
national policy we need to advise you to make sure your local policies
are consistent.

According to the comments we have received from the field, the most
contentious areas for debate are the "terminal illness" requirement
whereby only those patients with a terminal illness can request/receive
a DNR order and the restriction on the role of house officers, whereby
house officers are not allowed to enter a DNR order without a
countersignature from an attending physician. Ken, I will turn it back
to you to continue on with the discussion.

**Dr. Berkowitz:**

Thank you Kate. As you point out, current DNR policy contains several
controversial points, and we selected the two that she has mentioned for
the main focus of today's discussion. And to begin the discussion I
would like to return to VHA Central Office and hear from Mike Cantor.
Mike is a physician and a lawyer. He is Special Assistant to the
Director and the Policy Coordinator for our Center. Mike, let's start
with the policy requirement that patients must be terminally ill to be
eligible for Do Not Resuscitate status.

**Dr. Cantor**:

Thanks Ken. One of the comments we received regarding the DNR policy, as
you and Kate have noted, is a critique of the requirement that a patient
has to be terminally ill to have a DNR order. Current policy, M-2, Part
I, Chapter 30, Section 30.04 b states that "no patient shall be
considered for DNR order...in any case where the patient does not have a
terminal illness." Terminal illness is defined in 30.03 b. 1 as \"a
debilitating condition which is considered to be medically incurable or
untreatable in terms of current available technology, and which can be
expected to cause death...'Terminal illness' definitions need not
require that death be 'imminent' and may include in their scope chronic
conditions for which there is no hope for recovery." The ethical problem
that many people pointed out in their comments on this policy is that it
limits the patient's autonomy, that is, the patient's right to make
choices about which medical treatment to accept or reject. Generally
speaking, competent patients are allowed to refuse any medical
intervention including cardiopulmonary resuscitation (CPR) even when
refusing the treatment or procedure may lead to the patient's death. The
current policy places a limit on autonomy that is not consistent with
our current understanding of the rights of patients. Many people in the
field pointed that out. Legally speaking, the courts have recognized
that the ethical right to autonomously determine which medical treatment
to accept or reject is protected by our constitution as well as by
common law rights to be left alone. In order words, patients have legal
rights, as well as ethical ones, to reject any medical intervention.
Given that the current policy limit on autonomy seems to be out of touch
with current ethical and legal standards, we are considering changing
the policy to remove the terminal illness requirement. Ken.

**Dr. Berkowitz:**

It certainly is true that VA is committed to respecting patient
autonomy. At the same time VA remains committed to supporting and
sustaining the lives of our patients. That VA health care providers
remain committed to the general objective of sustaining our patients'
lives is imperative and must remain a priority. This is not meant to
undermine the patient or the provider's autonomy. In VA we are also
committed to creating an environment that promotes collaborative
decision making between clinical staff and patients or their surrogates.
In this spirit checks and balances in the system makes sense. By
removing the terminal illness requirement from the DNR policy, we will
lose what some have viewed as an important safeguard in our policy. When
a patient who is not terminally ill or is not in the later stages of
their life requests

DNR status, it is the exception rather than the rule, and without
clarification it does not inherently make sense. At that time, it is the
provider's duty to facilitate communication and assure that this request
is actually a true expression of the patient's wishes. Is the patient
truly informed? Do they understand the risks, benefits and alternatives
to resuscitation vs. DNR status? Do they know that healthier people tend
to have better outcomes from resuscitation? Do they know that DNR status
removes any chance of survival after an arrest? Do they know that
appropriately drafted advanced directives with instructions for time
limited trials of therapy and/or instructions to withdraw or withhold
life sustaining treatment if prognosis for recovery drops below certain
levels can allow the possibility of a successful resuscitation while at
the same time minimizing chances of surviving in an unacceptably
debilitated or vegetative state. The requirement for terminal illness
prior to DNR eligibility is not all bad. It forces us to question what
the relatively healthiest of our patients are actually saying when they
request DNR status. What do they fear as being worse than death? If we
understand this, we can generally devise a plan that will simultaneously
alleviate fears and allow for a chance at continued life through
resuscitation. Without some sort of policy barrier to DNR status in
relatively healthy patients, there is a fear that misconception,
misunderstanding and/or miscommunication might lead to errors at this
critical step in the development of a treatment plan. Policy that
assures thorough communication when a request for DNR status is less
than intuitively appropriate affirms our system's commitment to patient
autonomy by mandating that the wishes of the patient or surrogate are
truly informed, clarified and understood by all.

Mike, the other point for discussion today is the absolute requirement
that only attending level physicians can write DNR orders. Please let us
know what is being considered on this front.

**Dr. Cantor:**

Thanks. Let me begin by reviewing the current policy. M-2, Part I,
Chapter 30, Section 30.03, Part IV states that, "The physician who is
responsible for determining the propriety of a DNR order in a particular
case is the senior attending or staff physician, not a house officer."
In Section 5 it says, "the \[DNR\] order must be written or, at a
minimum, countersigned by the attending physician, rather than merely by
a house officer or resident, into the patient's medical record.
**Note:** *A verbal or telephone order for DNR is not justifiable as
good medical or legal practice.* Once the order has been entered, it is
the responsibility of the attending physician to ensure that the order
and its meaning are discussed with the appropriate members of the
medical center staff, particularly the nursing staff, so that all
involved professionals understand the order and its implications."
Although the language in this policy is not crystal clear, the National
Center for Ethics has consistently interpreted this to mean that house
officers are precluded from entering DNR orders. There are three main
reasons for this policy.

First, house officers may not have the prognostic skills to ascertain
when a DNR order is the best option for a particular patient. The
literature suggests that prognostic skills improve with experience, but
that house officers lack skills in predicting likely outcomes for
seriously ill patients.

The second reason is that house officers may lack communication skills
needed to sensitively discuss foregoing CPR. One study found that house
officers provide inadequate information for the patient to make an
informed choice by failing to discuss the likelihood of survival. House
officers also fail to elicit the patient's values and concerns by asking
the patient questions about preferences for specific procedures, but
neglecting to ask about health care goals. Finally, the study found that
when house officers begin to discuss their patients' concerns and
treatment preferences they tend to dominate the discussion and not allow
time for patient feedback. So the lack of communication skills are the
second reason.

The third reason is that ultimately it is the responsibility of the
attending physician to assure that the patient really wishes to be DNR,
and that the communication regarding the decision to forego CPR has been
carefully and competently handled.

The downside of the policy is the reality that at times the only
physicians in VHA facilities are house officers. Not allowing house
officers to write DNR orders means that patients admitted on weekends,
holidays, evenings or nights may wish to be DNR but cannot have the
order written. There is the risk that the patient could arrest before
the order is written, and that the patient would receive unwanted CPR or
worse, a "slow code," where half-hearted efforts are made to resuscitate
the patient. Performing unwanted CPR not only violates the patient\'s
rights to refuse care and inflicts a potentially and harmful treatment
on a dying patient. How then should VHA policy address this question?

One option is to permit house officers to enter a non-renewable DNR
order that will be valid for 24 hours and requires a co-signature from
the attending physician. In order to maximize the quality of this
process, additional safeguards could be added. For example, the order
would not be valid without the house officer discussing the order with
the attending and having the attending give verbal confirmation of the
order to a nurse or other member of the care team. Another potential
safeguard would be to ensure that only house officers with adequate
communication skills were permitted to obtain and write DNR orders. This
could be done by not allowing interns to write DNR orders or by
requiring that house officers demonstrate clinical competency in
discussing DNR orders before being permitted to write them. Alternatives
to temporary house officer written DNR orders include keeping the status
quo or giving attending physicians remote computer access so that they
can enter the order after having conversation with the house officer and
confirming it with other members of the care team.

**MODERATED DISCUSSION**

**Dr. Berkowitz:**

Thank you Mike. That still leaves us a good 20 or so minutes for open
discussion of today's topic. We know there are many other points related
to DNR policy that are worth discussing, but let's start today's open
discussion by sticking to the terminal illness and attending physician
requirements that we have presented. Please feel free to start by
introducing yourself and telling us what you think.

**Dr. Paul Jensen, VA Medical Center, Reno:**

I'm a medical ethicist here and involved in this process for over 30
years. I strongly support what Dr. Cantor first mentioned about
broadening the scope here of the terminal illness category to include
debilitating chronic conditions. I think that as often as not, we find
in our veteran population severe COPD patients, patients who had
multi-infarct dementia problems, etc., and typically they are brought in
in the middle of the night and when the family feels there is some
crisis when they don't want to have the patient die at home or whatever,
they bring him in in the middle of the night and there's a very good
chance they're going to code on the ward and then end up as what
happened here to us a couple of months ago. An 82-year-old gentleman
with all kinds of problems came in in the middle of the night and coded
on the ward. He remained comatose but he ended up on a ventilator in the
Intensive Care Unit until finally we got a family conference and the
family asks, "Why did you attempt resuscitation on this patient?" So we
weaned him off of the ventilator but he still survived comatose and he
died two days later on the ward. Again, the family was very incensed
about why we even attempted the resuscitation. They wrote a letter to
the Director, which we had to respond to, etc. That's the scenario we
see most often here.

**Dr. Berkowitz:**

Thank you. What I would like to do is just to clarify. I would like to
read from the current policy the definition of terminal illness so we
can make sure we are all clear on exactly what VHA's definition is.
Terminal illness is defined as "a debilitating condition which is
considered to be medically incurable or untreatable in terms of
currently available technology and which can be expected to cause death.
In situations involving terminal illness as defined it may be concluded
that resuscitation would be of no benefit to the patient and that the
institution of resuscitative measures, if successful, would only
postpone death. Terminal illness definitions need not require that death
be imminent, and may include or already include in their scope, chronic
conditions from which there is no hope for recovery." Dr. Jensen,
patients such as the one mentioned and used as an example as with end
stage chronic obstructive pulmonary disease or other end stage
conditions or vegetative conditions can be considered terminal according
to VA's current definition and would be eligible for DNR status if that
was the decision that was made as a result of discussion with the
patient or their surrogate.

**Dr. Jensen**:

Yes, I agree. I think the current definition the way it reads is a broad
one. But I was preferring the response that initially came from Dr.
Cantor versus the kinds of things you were enunciating after his
comments. I think that clearly, and probably most frequently, these
patients who are like metastatic cancer patients and a variety of other
chronic conditions typically they may not really be terminal as such in
the sense that the usual definition of terminal is six months, but
broadly defined, but I think debilitating chronic illness, incurable
chronic illnesses should be very, very strongly expressed element of
that definition. I would say instead of terminally ill, I would say
terminal illness or debilitating or advanced chronic illness.

**Kathleen Douris, VA New York Harbor HCS, New York, NY:**

Two points. I don't find that the definition of terminal illness is
unacceptable by any means. It covers a broad range. What I find is a
problem is application. And in those cases when you are considering DNR
orders with the exception of perhaps home based primary care, nobody
that is an outpatient walks around with a DNR order unless they are on a
hospice type of team. So I think the idea is that it is not deficient as
a definition of terminal illness. It is a fact that nobody in an
outpatient clinic with those types of patients has probably dealt with,
talked with issue of DNR for outpatients, which is really when you can
have more time to discuss patient's values, their wishes, their
knowledge of their condition and all those sorts of things because we
all know, particularly with the end stage COPD patients, when they get
put on oxygen, it is very likely that they are going to show up in the
condition that the previous caller described. And that it is entirely
appropriate at that time to start and have some discussion about it. So
I don't find that the definition is problematic, it is our application
and our approach to patients to look at and to discuss those issues up
front. The second thing is with the issue of who should be writing the
DNR orders. I've talked with the Nurse Practitioners in the Home Based
Primary Care Unit here, and most of the time we are the providers who
are talking with the patients, are very familiar with their wishes and
their values and have conversations with them, certainly over months if
not years in some cases, and have knowledge of their medical condition
as well. So a lot of times we are initiating those discussions and
integrating the patient's wishes as well in a very appropriate way.

**Dr. Berkowitz:**

So Kathleen, are you saying that you think Nurse Practitioners should be
able to write such orders?

**Ms. Douris:**

Absolutely. Dependent upon having competencies and being able to
communicate effectively and having knowledge of the patient's prognosis,
as with residents and others. I am saying that there are Nurse
Practitioner providers as well as housestaff that could be appropriately
trained and could be doing this particular task. As it is now, for some
nurse practitioners in Home Based Primary Care or the nurses in some
cases may be explaining this to patients and attending physicians
signing the form based on the nurse practitioner's judgment and review
of that patient and review of the chart materials.

**Dr. Berkowitz:**

Mike, I know this was something that was discussed. Any comments?

**Dr. Cantor:**

Yes. I think the idea is that we want to make certain that people who
have a good idea of the patient's prognosis and are able to communicate
well with a patient and/or their family, certainly in a long term care
or primary care setting, are the people who are entering DNR orders. And
I think we are trying to figure out how to assess competency. What I
didn't say in my brief comments is that we know from other studies that
physicians, the one's who we now allow to write DNR orders, aren't
necessarily the most skilled in discussing CPR or having other end of
life decisions with patients. What we really need to do is consider how
we improve the quality of that process overall, not just for house
officers, nurse practitioners or physicians or physician assistants, but
for all health care practitioners. We need to consider this more broadly
and some commentators who sent us comments actually did ask us to
consider whether or not nurse practitioners and PAs would be allowed to
write DNR orders. There are ways we could write the policy to permit
that, probably by applying the same rules as for house officers.

The other thing I wanted to mention is the whole question of outpatient
DNR. This, it turns out, is a more complicated question than it might
appear. DNR orders are only valid when a patient is actually within an
institution, whether that be acute care setting or long-term care
setting. So patients living in the community, if they are to have DNR
orders, generally those DNR orders come under the auspices of the state
emergency medical system, because the people who respond to them are the
EMTs who are driving ambulances and who come on to the scene when the
person is arresting, and they have to know immediately whether or not
they should implement resuscitative efforts. Because this is a state
organized system, the rules depend on state law in some cases, and in
other states they don't have a law but they have a regulation that is
promulgated by the State Department of Public Health or whatever
administrative agency oversees emergency medical services. In other
states it's not the overall state agency, but there are regional
emergency medical service systems and they have their own rules.
Different parts of the same state will have different protocols.

Our problem in VA is that we would like to have one standard and yet we
have state rules that would apply. When we have discussed this in the
past with General Counsel there are concerns that VA providers would be
subject to state rules which may not be consistent with VA policy or may
put VA providers at risk for liability in a way that our Counsel doesn't
feel comfortable. There is also the issue that many of these states
require that the practitioner be licensed in that state in order to
write a valid order for a particular patient. So you can imagine in a
metropolitan area like here in Washington, DC where patients come from
Virginia, Maryland, the District, West Virginia, that it would be
difficult working at the DC VA Medical Center\--seeing patients from
three surrounding jurisdictions as well as the District might then
require licensure in all those states. How we could enable patients who
wanted to be DNR and living in those other states is something that
would have to be worked out locally. What we suggested about this in the
past is that each facility should work with their local Counsel to
figure out what the state rules are locally and how VA policy and state
rules can be made consistent, if that is possible. As we discuss
expanding our DNR policy, this issue of out of hospital DNR is
definitely one of the issues we are going to take up and we will work
with our working group and with Counsel to see how we can come up with a
policy that makes sense.

**Dr. Berkowitz:**

Thanks Mike. Just to reiterate, and please clarify if I'm wrong, but
there is nothing in current VA policy that prohibits a physician from
writing an out of hospital DNR if it is in accordance with the
jurisdiction where they are.

**Dr. Cantor:**

Well I think that is true, although local Counsel still should be
contacted before VA providers begin doing that. Because when a VA
provider does that, they are effectively directing non-VA personnel, in
other words, the EMTs, and lawyers are concerned about liability
questions that may arise in that circumstance.

**Dr. Stephen Wear, Buffalo, VA, Buffalo, NY:**

I'm a little concerned because I think there is a more basic issue here,
and that is simply as was initially mentioned, I think by Mike Cantor in
his summary, it seems absolutely clear to me after a quarter century
working in bioethics that the current understanding of the field, and
it's been that way for over a decade, is that terminal illness, although
I concur with almost every comment that Ken Berkowitz made, that we have
to be concerned about patient's understanding, communication, and all
the rest, that in the end it is not appropriate if we have a competent
patient that knows what they are saying, competence has been assessed,
they've discussed it with us and they just look us in the eye and say,
"We can talk about whatever else you want to do, but if I get so sick
that I actually arrest, I do not want to be touched." Okay. How the VA
could possibly say that we should say to them, sorry, but you are not
terminally ill in terms of our definition, we are going to code you, and
if you don't like that, you have to go elsewhere. I can't see how we
would say it. The other thing I would just thrown in quickly. I think it
is absolutely a contradiction at the heart of it, at the VA, if you look
at the informed consent policy, it requires informed consent for every
treatment. If you look at the advanced directive policy, everything
other than DNR, again the patient's have the right to refuse it. If that
isn't enough, everybody should go look at the first paragraph of the
patient's Bill of Rights. Patients have the right to refuse any and all
treatment. I think we can talk about safeguards, better communication
and all the rest, but in the end if there is any sense that the terminal
illness definition is retained, no matter how disingenuously we redefine
it, as if the VA has a right to do that, there are still going to be
patients like the otherwise healthy 80 year old that says, "Honey, we
could talk about what you think you might be able to do for me, but if I
get that bad, leave me alone." And if somebody knew the literature on
codes, a lot more people might say that. I can't see how you guys can
push that as an absolutely requirement. It is simply an infringement on
patient autonomy, that it is medieval at this point.

**Dr. Jensen:**

I applaud totally with what Dr. Wear has just expressed. Considering a
very low percentage of success rates with CPR, I think this is very
relevant. The overall analysis studies show 15 percent survive, leave
the hospital alive, and many of our veterans here with advanced illness,
why, they are down to just a fraction of that percent, many of them.

**Dr. Wear:**

Just take an 80-year-old on the ward, what are the chances there? Or
take a look at the code statistics. Over and over again, if I were an
elderly patient, given what I know about the code statistics, I would
really think about it unless I was in the OR or in the ICU, I would
think about a DNR.

**Dr. Cantor:**

If perhaps I can respond. I think that we recognize and I think you
summarized very nicely sort of the arguments against retaining the
terminal illness requirement. The overwhelming majority, I think every
comment except for one, basically supported eliminating this from our
policy, which as you mentioned before, was written in 1994. So it is
time for us to revisit it and to improve it. I think what Ken's point
was is that this terminal illness requirement in some ways has served as
a safeguard or a check to make certain that people really do understand
what they are asking for or what they mean when they don't want to be
resuscitated. You and I may know that the overall success rate for
witnessed arrest in the hospital may be about 15% and that depending on
the cause of the arrest, the type of arrest, that numbers especially for
older people or people with several functional impairment or chronic
illness, that those numbers are significantly lower. You and I may know
that, but remember that people in the public watch "ER" and there's
actually a paper on that showing that the success rate on "ER" is much
higher and people's perception of the success rate is out of line with
the reality of 15% or less. Given that, I think there is a need for us
to make certain that when we have this conversation, that people really
know what their choices are, what the implications are, risks benefits
and alternatives, and if that is what they want, even if they are not
terminally ill, then I think it is fine probably for them to request it.
The issue is, how do we take this good thing of having a check and
balance on willy-nilly writing DNR orders and come up with a policy that
clearly requires good communication, rather than defining the people who
don't have terminal illnesses as being somehow suspect class if you
will, of people who want DNR.

**Dr. Wear:**

Mike, why don't you take the comments you just made and the comments
that Ken Berkowitz made about the problems we need to address, and find
another way to deal with them. I don't believe the terminal illness
requirement provides that safe guard. It's just another thing that can
be checked by a resident who is hurried, who isn't talking to anybody,
and those are all issues I think we all agree, and there are any number
of ways to do that including requiring extensive documentation, training
people and all the rest. Those are the things that we need to do. The
terminal illness thing just puts us back in 1985.

As somebody that's a student of bioethics back in 1985, it was like
pulling teeth to get a DNR order and people felt different if the
patient was terminally ill. In any other venue that I know of, that
requirement has simply gone by the boards. It's just another think box
you can check or not check.

**Dr. Peg Ballard, Hines VA, Chicago, IL:**

I want to start with a technical comment. In CPRS orders cannot be
co-signed. It is technically impossible to have an order that gets a
co-signature. So what you have required in this, if you allow the
resident to write the order, there is no way to have a co-signature of
an order. Now we have sidestepped that at Hines because with each order
there is an accompanying note, so you can call for a co-signature on a
note. So the attending will co-sign the note the next day the resident
has written or in the morning or whatever or two hours later, whenever
that timeframe may be, but again this is where CPRS is different from
the paper sheet. I just want to point out this reality check to you. You
can ask for it in the directive, but it cannot be done as CPRS is
currently configured.

The other thing I wanted to say, if I could just finish briefly, is when
I read the current directive, I agree, it is very 1980ish, and it makes
the presumption that DNR is something that the doctor does to the
patient with little or no input from the patient. It's a whole mindset
thing that a doctor makes a terminal patient DNR because the doctor in
their omnipotence mode has decided that the patient is terminal. I just
think that the whole tone of it, to reinforce what everyone has said,
needs to change and have a balance. When the patients, even in my
opinion a 40-yr old patient, who tells me, "Thank you very much doctor
but I do not want to be resuscitated, even though I don't have any
terminal illness that's been identified." I really feel I have to honor
that. And I'm a geriatrician, so most of my patients aren't 40 years
old, but I've got a 40-yr old guy with an osteomyelitis in my nursing
home unit right now. He's been here for six months and he doesn't want
to be resuscitated in the case of an arrest. I don't think he is going
to arrest, but I feel that to respect his autonomy, that I have to honor
that. And again, this guy has no terminal illness. So I just think there
just needs to be a big rebalance. I think in cases where there may not
be patient or family input, then I think the system that you have set up
is reasonable for protecting the patient, but I do think that's the
unusual case today. The more run of the mill thing is a patient comes
and says, "Thank you very much, but no thank you."

**Dr. Linda Williams, Little Rock VA, Little Rock, AR:**

I have several comments. First of all, regarding the technical issue of
the computer. I've confirmed within the last week that we cannot do
co-signatures here. I did this because of this exact issue on our DNR
orders. Secondly, I need to go back to that initial presentation, the
patient that came in with COPD, that ended up resuscitated and comatose.
I did not hear, had this patient or family expressed prior wishes? Was
there some way they expected the physicians to know that this patient
and family did not want him resuscitated previously?

**Dr. Jensen:**

You bring up a valid point. The family said they had done that. That
they had filled out an advance directive. But after extensive search, we
were unable to find it. But the whole issue could have been avoided had
the subject been raised when the patient was admitted in the middle of
the night.

**Dr. Williams:**

My concern here is that I do agree that the terminal illness definition
is not only unhelpful, but it hinders our discussion of care with the
patient, because how do you discuss care with the patient, then when
they tell you they want to choose it for an option, you have to tell
them you cannot write that option. Age, I believe, should not be a
criteria in this.

**FROM THE FIELD**

**Dr. Berkowitz:**

As usual, we did not expect to conclude the discussion in that time
allotted. And we have run out of time for this portion of the call. We
do make provisions to continue the discussion in an electronic form on
the Webboard that can be accessed through the VA National Center for
Ethics Website, and we also post on the Website a very detailed summary
of this and each and every Ethics Hotline Call. So please visit our
Website to review or continue today's discussion. You will also be
getting a follow-up e-mail for this call with the links for the
appropriate Website and Webboard discussion. One of the goals of this
series of hotline calls is to facilitate networking among ethics related
VA staff and to facilitate communication between the field and our
center. So we save the last portion of each call for our 'From the
Field' section. And this is your opportunity to speak up and let us know
what is on your mind.

**Dr. Jensen:**

This is Dr. Jensen again. I would suggest we change the term DNR to DNAR

\- Do not attempt resuscitation. I'm in the American Heart Association
now, and its 2001 revision of the manual is reflecting this recognition.
Considering the low response rate to CPR, I think it is more
appropriate, and many hospitals have done that, Univ. of
Washington-Seattle, Univ. of California-Stanford, etc. use DNAR instead
of DNR.

**Dr. Berkowitz:**

I know that is a suggestion that many people have made and it is
certainly one that is being considered.

**Dr. Cytryn, Bronx VA, Bronx, NY:**

I'm coming from a slightly different perspective. Our spinal cord
injured patients might be considered in that group of patients who are
"terminal" in that they have a disease for which medical science has no
cure, and our life expectancy for a patient, especially for paraplegics,
is in terms of decades, so I have problems with using the term
"terminally ill" because according to the definition you are using of
terminally ill, all of my patients, I could write DNR orders any day I
want, and I don't know whether or not it would be appropriate.

**Dr. Berkowitz:**

Excellent point.

**Ladonna Golden, Central Alabama HCS, Montgomery, AL:**

I think that is where your advance directives come to play. One of the
issues comes up that we have so many different directives. We've got one
on Do Not Resuscitate, we've got one on advance directives, and really
those kind all are a part of the same process. Maybe if we tried to
realign those regulations so that everything flowed in the process and
be different topics of that same regulation, we wouldn't have as much
confusion. Because the advance directive truly plays a very pivotal part
of the Do Not Resuscitate, if it is implemented appropriately.

**Dr. Berkowitz:**

Right. And I know you folks down in Central Alabama have worked hard to
try to consolidate some of these into one local policy.

**Ms. Golden:**

Right, we do have one policy. We also have done templates in CPRS where
we have the required documentation information with the co-signature on
those. And that is mandatory with a DNR order.

**Dr. Wear:**

We've done that in VISN 2 in New York State also with the single policy
that is now VISN-wide and with a lot of work in CPRS drop down menus,
templates, and all the rest. You folks at the National Center, I would
suggest to you, I sent my stuff, I suspect Alabama might have too.
There's a lot of work that has already been done out there. There are
wheels that have already been built. And hopefully the group will in
part look at those.

**Dr. Cantor:**

We do have the materials and we will incorporate them in our discussion.
We don't intend to reinvent the wheel. Those are helpful to have. Thank
you.

**Wilmington, DE**:

I have one thing I wanted to refer to. It's a totally different topic.
It's on surrogate decision making. Recently we came across a case where
the surrogate decision-maker was a common law wife. We find that the
states all have different laws in regards in common law. Delaware, for
instance, does not honor common law. We referred this to Regional
Counsel and they really found that this was almost an unanswerable
question. Since common law comes up frequently, as far as decision
making for patients, I would like to see this looked at from a national
level.

**Dr. Berkowitz:**

One thing I can tell you is that if you have a patient who has a
significant other or a common law spouse, from a practical standpoint
until this gets settled, we think it is especially important to work
with those patients to see if they are interested in filling out a
Durable Power of Attorney for Health Care, so they can actually have
those people appointed as a decision maker, if that is really what they
wish.

**Ms. Angela Prudhomme, Office of General Counsel:**

With respect to the common law spouse, there are rules that apply to
this and the person has to be the legal spouse under the state law. So
if that state -the person is a legal spouse, then they would have
priority as the legal spouse.

**Dr. Berkowitz:**

Sorry, I have to cut you off because I have less than a minute left. If
you have further comments, please put them on the Webboard for further
discussion. I really need to thank everyone who has worked hard on the
conception, planning and implementation of this call. It's never a
trivial task and I appreciate everyone's efforts, especially Kate and
Mike for their presentations. The next call will be Tuesday, April 23,
from 12 to 12:50 Eastern Time. Please look to our Website and to Outlook
e-mail for details and announcements. I will be sending out a follow up
e-mail for this call with the addresses and the links you can use to
access our center, the summary of our call and the electronic web board
discussions. And remember, the summary and discussion of prior calls are
also available and ongoing. Please let us know if you or someone you
know should be receiving announcements for these calls and didn't or we
always love to hear about suggestions for topics for future calls. Again
our e-mail address is vhaethics@med.va.gov. Thank you.