Universal Do-Not-Resuscitate Orders, Social Worth, and Life-Years
Authors: Eric C.T. Geijteman, Frank H. Bosch, Yvo M. Smulders
Journal: Annals of Internal Medicine (2020)

Letters15 December 2020Universal Do-Not-Resuscitate Orders, Social Worth, and Life-YearsFREEEric C.T. Geijteman, MD, PhD, Frank H. Bosch, MD, PhD, and Yvo M. Smulders, MD, PhDEric C.T. Geijteman, MD, PhDErasmus MC Cancer Institute, Rotterdam, the Netherlands (E.C.G.), Frank H. Bosch, MD, PhDRadboudumc and Rijnstate Hospital, Nijmegen and Arnhem, the Netherlands (F.H.B.), and Yvo M. Smulders, MD, PhDAmsterdam University Medical Center, Amsterdam, the Netherlands (Y.M.S.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/L20-1196 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:Bledsoe and colleagues (1) recommend against a blanket approach to deciding not to attempt resuscitation. In the scenario they describe, all patients with a particular diagnosis—such as coronavirus disease 2019 (COVID-19)—would have a do-not-resuscitate (DNR) order. We would like to reflect on this position. Implementation of universal DNR orders has been suggested during the COVID-19 pandemic in order to maximize resources and limit possible exposure to health care professionals (2). To maximize resources, we believe that there is a very important step between current practice and the draconian decision to implement universal DNR orders, namely, unilateral DNR orders. In such an approach, the decision not to resuscitate is made by the attending physician.Bledsoe and colleagues suggest that unilateral DNR decisions rarely played a role before the COVID-19 pandemic (3). However, in the Netherlands, such decisions have been an everyday option for several decades. The attending physician is allowed—or, in fact, morally obligated—to make this decision if cardiopulmonary resuscitation (CPR) is not considered potentially successful. This is frequently the case in fragile patients and those with an infaust prognosis. This practice is based on the belief that decisions about resuscitation should be based on not only the patient's values, goals, and beliefs but also the medical usefulness of the treatment (4). A unilateral DNR decision is preferably made by a physician with whom the patient has had a long-term relationship.Decisions about DNR orders should be explained to patients and relatives with patience and empathy, emphasizing that all reasonable efforts to cure the patient will be used and that the patient will be cared for if cure is no longer possible. A large subsequent nationwide Dutch study on end-of-life decision-making practices showed that in 1990, a total of 37% of all DNR decisions were made without involving the patient and their relatives (5). This proportion fortunately has decreased markedly to 4% in 2001 and 1% in 2010, which shows that reaching a DNR decision on the basis of medical futility is perfectly compatible with appropriate involvement by the patient and their relatives (5).The COVID-19 pandemic has made clear that interventions aimed at prolonging life, such as CPR and mechanical ventilation, are not always in a patient's best interest. As physicians, we should take the lead in completing DNR orders in patients in whom CPR is not considered potentially meaningful. Doing so may help better allocate resources without undermining patient-centered care.References1. Bledsoe TA, Jokela JA, Deep NN, et al. Universal do-not-resuscitate orders, social worth, and life-years: opposing discriminatory approaches to the allocation of resources during the COVID-19 pandemic and other health system catastrophes [Editorial]. Ann Intern Med. 2020;173:230-2. doi:10.7326/M20-1862 LinkGoogle Scholar2. Cha AE. Hospitals consider universal do-not-resuscitate orders for coronavirus patients. The Washington Post. 25 March 2020. Accessed at www.washingtonpost.com/health/2020/03/25/coronavirus-patients-do-not-resucitate on 29 May 2020. Google Scholar3. Curtis JR, Kross EK, Stapleton RD. The importance of addressing advance care planning and decisions about do-not-resuscitate orders during novel coronavirus 2019 (COVID-19). JAMA. 2020;323:1771-2. [PMID: 32219360] doi:10.1001/jama.2020.4894 CrossrefMedlineGoogle Scholar4. Billings JA, Krakauer EL. On patient autonomy and physician responsibility in end-of-life care. Arch Intern Med. 2011;171:849-53. [PMID: 21555664] doi:10.1001/archinternmed.2011.180 CrossrefMedlineGoogle Scholar5. Geijteman EC, Brinkman-Stoppelenburg A, Onwuteaka-Philipsen BD, et al. Two decades of do-not-resuscitate decisions in the Netherlands [Letter]. Resuscitation. 2015;94:e7-8. [PMID: 26193377] doi:10.1016/j.resuscitation.2015.06.028 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment John A StewartNot applicable (retired)1 January 2021 Another way to avoid universal DNR orders In the search for approaches to in-hospital reuscitation in the setting of Covid-19, the authors understandably eschew "the draconian decision to implement universal DNR orders," while recognizing that efforts will most likely prove futile. They propose accepting unilateral DNR orders from physicians on a case-by-case basis. Another possible approach is universal "limited resuscitation" orders. Limited to what? Perhaps to the most effective (and indeed only) definitive treatment for cardiac arrest: rapid defibrillation. ILCOR has pointed the way by advocating defibrillation without full PPE, with the rationale that the procedure is unlikely to generate aerosols. For every coding patient, a caregiver (probably with an N95 mask) would enter the room with a defibrillator, initiate bedside monitoring, and defibrillate if indicated. If it was not a shockabe rhythm, the code could be ended: no need for chest compressions or for multiple people donning PPE and entering the room. So, no universal DNR orders: every patient would have a chance at having a shockable rhythm and getting further treatment. Doing nothing is an uncomfortable option for caregivers and can be heartwrenching for families, but doing just this much will give patients their best chance at survival while decreasing the vast resources necessary for full codes. Author, Article, and Disclosure InformationAffiliations: Erasmus MC Cancer Institute, Rotterdam, the Netherlands (E.C.G.)Radboudumc and Rijnstate Hospital, Nijmegen and Arnhem, the Netherlands (F.H.B.)Amsterdam University Medical Center, Amsterdam, the Netherlands (Y.M.S.)Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=L20-1196. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoUniversal Do-Not-Resuscitate Orders, Social Worth, and Life-Years: Opposing Discriminatory Approaches to the Allocation of Resources During the COVID-19 Pandemic and Other Health System Catastrophes Thomas A. Bledsoe , Janet A. Jokela , Noel N. Deep , and Lois Snyder Sulmasy Metrics Cited byEnd-of-life discussions reduce the utilization of life-sustaining treatments during the last three months of life in cancer patients 15 December 2020Volume 173, Issue 12Page: 1028-1029KeywordsCOVID-19Cardiopulmonary resuscitationConflicts of interestDisclosureDo not resuscitate ordersHealth careResuscitationVentilators ePublished: 15 December 2020 Issue Published: 15 December 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...