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Challenges of Do-Not-Attempt-Resuscitation Orders

Challenges of Do-Not-Attempt-Resuscitation Orders To the Editor: Dr Blinderman and colleagues1 discussed a default position of not performing CPR for imminently dying patients in US hospitals unless consent to opt-out is obtained. Similarly, a physician may deem CPR futile and may wish to enter a do-not-attempt-resuscitation order over the objections of the patient or family. Although it may be ethically and medically justified in certain situations, the bulk of case law and statutory interpretation does not support the use of such a hospital policy. The federal Fourth Circuit Court of Appeals decided in Inre Baby K2 (citing the Emergency Trauma and Labor Act) that emergency department physicians must provide stabilizing care to all patients regardless of the standard of medical practice. In Thornton v Southwest Detroit Hospital,3 the federal Sixth Circuit Court of Appeals applied this Act to inpatients as well, effectively mandating that all patients in extremis receive stabilizing care, although other federal Circuit Courts of Appeal have rejected the application to inpatients. New York Public Health Law §2962 contains a presumption in favor of CPR. In 2003, then acting Attorney General Elliot Spitzer interpreted the statute as prohibiting the writing of a do-not-attempt-resuscitation order over the objection of the patient or a surrogate, even if the attending physician deemed CPR futile.4 Gilgunn v Massachusetts General Hospital5 and Wheelock v Doers6 provide some weak support for a default option of not attempting CPR. In Gilgunn, a jury affirmed that physicians are not required to perform interventions that are deemed medically futile. In Wheelock, the published opinion contains gratis dictum support for physicians not providing interventions that are deemed medically inappropriate. In the hope of protecting physicians who in good conscience withhold certain medical interventions, several states have passed statutes based on the Uniform Health-Care Decisions Act. However, in Baby K,2 the court specifically held that the Emergency Trauma and Labor Act preempted Virginia's version of the law. Only the version of the Uniform Health-Care Decisions Act in Texas seems to have had any success in limiting medically futile care. Although I agree with Blinderman et al1 that not offering CPR is appropriate in certain cases, society in the United States does not seem ready for such an approach. Back to top Article Information Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. References 1. Blinderman CD, Krakauer EL, Solomon MZ. Time to revise the approach to determining cardiopulmonary resuscitation status. JAMA. 2012;307(9):917-91822396511PubMedGoogle ScholarCrossref 2. In re Baby K, 16 F3d 590 (4th Cir 1994) 3. Thornton v Southwest Detroit Hosp, 895 F2d 1131 (6th Cir 1990) 4. NY Atty Gen Opinion No. 2003-F1 5. Gilgunn v Massachusetts General Hospital, No. 92-4820 (Mass Sup Ct Civ Action Suffolk Co; April 22, 1995) 6. Wheelock v Doers (Tenn App 2010) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Challenges of Do-Not-Attempt-Resuscitation Orders

JAMA , Volume 307 (23) – Jun 20, 2012

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Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.2012.5605
Publisher site
See Article on Publisher Site

Abstract

To the Editor: Dr Blinderman and colleagues1 discussed a default position of not performing CPR for imminently dying patients in US hospitals unless consent to opt-out is obtained. Similarly, a physician may deem CPR futile and may wish to enter a do-not-attempt-resuscitation order over the objections of the patient or family. Although it may be ethically and medically justified in certain situations, the bulk of case law and statutory interpretation does not support the use of such a hospital policy. The federal Fourth Circuit Court of Appeals decided in Inre Baby K2 (citing the Emergency Trauma and Labor Act) that emergency department physicians must provide stabilizing care to all patients regardless of the standard of medical practice. In Thornton v Southwest Detroit Hospital,3 the federal Sixth Circuit Court of Appeals applied this Act to inpatients as well, effectively mandating that all patients in extremis receive stabilizing care, although other federal Circuit Courts of Appeal have rejected the application to inpatients. New York Public Health Law §2962 contains a presumption in favor of CPR. In 2003, then acting Attorney General Elliot Spitzer interpreted the statute as prohibiting the writing of a do-not-attempt-resuscitation order over the objection of the patient or a surrogate, even if the attending physician deemed CPR futile.4 Gilgunn v Massachusetts General Hospital5 and Wheelock v Doers6 provide some weak support for a default option of not attempting CPR. In Gilgunn, a jury affirmed that physicians are not required to perform interventions that are deemed medically futile. In Wheelock, the published opinion contains gratis dictum support for physicians not providing interventions that are deemed medically inappropriate. In the hope of protecting physicians who in good conscience withhold certain medical interventions, several states have passed statutes based on the Uniform Health-Care Decisions Act. However, in Baby K,2 the court specifically held that the Emergency Trauma and Labor Act preempted Virginia's version of the law. Only the version of the Uniform Health-Care Decisions Act in Texas seems to have had any success in limiting medically futile care. Although I agree with Blinderman et al1 that not offering CPR is appropriate in certain cases, society in the United States does not seem ready for such an approach. Back to top Article Information Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. References 1. Blinderman CD, Krakauer EL, Solomon MZ. Time to revise the approach to determining cardiopulmonary resuscitation status. JAMA. 2012;307(9):917-91822396511PubMedGoogle ScholarCrossref 2. In re Baby K, 16 F3d 590 (4th Cir 1994) 3. Thornton v Southwest Detroit Hosp, 895 F2d 1131 (6th Cir 1990) 4. NY Atty Gen Opinion No. 2003-F1 5. Gilgunn v Massachusetts General Hospital, No. 92-4820 (Mass Sup Ct Civ Action Suffolk Co; April 22, 1995) 6. Wheelock v Doers (Tenn App 2010)

Journal

JAMAAmerican Medical Association

Published: Jun 20, 2012

References