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But there will also be situations where clinicians are asked to discuss with a patient whether they want to or should have resuscitation if they have had a cardiac arrest or life-threatening arrhythmia. The potential likelihood for clinical benefit in accordance with the patient's preferences for intervention and its likely outcome, involves careful consideration, as with many other medical decisions, in deciding whether or not to resuscitate a patient who suffers a cardiopulmonary arrest. Therefore, decisions to forego cardiac resuscitation are often difficult.
Cardiopulmonary resuscitation (CPR) is a set of specific medical procedures designed to establish circulation and breathing in a patient who's suffered an arrest of both. CPR is a supportive therapy, designed to maintain perfusion to vital organs while attempts are made to restore spontaneous breathing and cardiac rhythm (Braddock 2).
The standard of care is to perform CPR in the absence of a valid physician's order to withhold it, if a patient stops breathing or their heart stops beating in the hospital. Paramedics responding to an arrest in the field are required to administer CPR. Some patients, however, may wear a bracelet that tells a responding paramedic to honor a physician's order to withhold CPR.
There are two general situations which may arise that justify withholding CPR: when CPR is judged to be of no medical benefit, also known as "medical futility," and when the patient with intact decision making capacity or someone designated to make decisions for them clearly indicates that, should the need arise, he or she does not want CPR. Virtually all hospitals have policies which describe circumstances under which CPR can be withheld. (Braddock 4).
When a resuscitation treatment offers no benefit, the physician is ethically justified in withholding resuscitation. It is important to define what it means to "be of benefit." The probability of an intervention leading to a desirable outcome is one way to define benefit. CPR, for instance, has been prospectively evaluated in a wide variety of clinical situations, yet the probability of success with CPR may be used to determine its futility. CPR has been shown to be have a 0% probability of success in circumstances such as septic shock, acute stroke, metastatic cancer or severe pneumonia. And survival from CPR is extremely limited in other circumstances such as in hypotension (2% survival), renal failure (3%), AIDS (2%), homebound lifestyle (4%), and age greater than 70 (4% survival to discharge from hospital) (Braddock 4).
Judging "quality of life" tempts prejudicial statements about patients with chronic illness or disability. CPR lacks benefit when the patient's quality of life is so poor no meaningful survival is expected, even if CPR could restore circulatory stability. There is probably consensus that patients in a permanently unconscious state possess a quality of life that few would accept, so CPR is usually considered "futile" for patients in a persistent vegetative state.
When a treatment is judged to be medically futile, the physician is under no obligation to provide it. But the patient and/or the patient's family should have a role in making the decision whether a DNR order is to be followed. This stems from respect for all people who take part in important life decisions. This is also commonly referred to as respect for autonomy or respect for person (Braddock 5).
If the family disagrees, ethicists and physicians are divided over how to proceed. If there is disagreement, every reasonable effort should be made to communicate the futility to the patient or the patient's family. Sometimes this will lead to a resolution. In difficult cases, however, an ethics consultant can prove helpful in the form of a meeting with the doctors, or with a religious minister. Nevertheless, resuscitation treatments should still be provided to these patients, even if judged futile.
Slow-codes," are a half-hearted effort at resuscitation is made, and are not ethically justified. These undermine the right patients have to be involved in inpatient clinical decisions, and violate the trust patients have in their physicians to give full effort. In some cases, the patient is clearly unable to voice a wish to have treatment withheld or withdrawn. As with DNR orders, there are two general approaches to this dilemma:
Advance Directives and surrogate decision makers (Braddock 5).
Advance directives are usually written documents designed to allow competent patients the opportunity to guide future health care decisions in the event that they are unable to participate directly in medical decision making." (Frequently 1).
Living Wills and Durable Power of Attorney: in some cases, a Living Will may spell out specific decisions while in the Power of Attorney it will designate a specific person to make health care decisions for them. There is some controversy over how literally Living Wills should be interpreted. In some cases, the document may have been drafted in the distant past, and the patient's views may have changed. Similarly, some patients do change their minds about end-of-life decisions when actually faced. In general, when they reflect long held, consistently stable views of the patient, preferences expressed in a Living Will are most compelling. Conversations with family members, close friends, or health care providers with long-term relationships with the patient may determine the patient's views.
Surrogate decision makers: In the absence of a written document, those familiar with the patient's wishes may be very helpful, such as people close to the patient and family. Though all close family members and significant others should be involved and reach consensus, the law recognizes the hierarchy of family relationships in determining which family member should be the official "spokesperson." The hierarchy is as follows:
Legal guardian with health care decision-making authority
Individual given durable power of attorney for health care decisions
Adult children of patient (all in agreement)
Parents of patient
Adult siblings of patient (all in agreement) (Braddock 5)
As long as a patient remains competent to participate in medical decisions, both Power of Attorney for Health Care documents and Living wills and are revocable. Decisions by competent patients supersede any written directive (Frequently 1). Sometimes the patient is awake, alert, and conversant, but their decisions seem questionable or irrational. First, it is important to distinguish an irrational decision from simple disagreement. If you feel strongly that a certain course of action is "what's best" for the patient, it can seem irrational for them to disagree. In these situations, it is critical to talk with the patient and find out why they disagree.
In general, the capacity to make treatment decisions, including to withhold or withdraw treatment, is considered intact if the patient:
understands the clinical information presented appreciates his/her situation, including consequences with treatment refusal is able to display reason in deliberating about their choices is able to clearly communicate their choice (Braddock 5).
If the patient does not meet these criteria, then their decision to refuse treatment should be questioned, and handled in much the same way as the clearly incompetent patient. When in doubt, an ethics consultation may prove helpful. A psychiatric consult may also be most helpful in these situations. Patients with active mental illness including depression should have their decision making capacity evaluated carefully. Depression and other mental disorders should prompt careful evaluation, which may often be helped by psychiatry consultation (Braddock 2).
The question of whether to withhold fluids underscores the importance of clarifying the goals of medical treatment. Any medical intervention can be withheld or withdrawn, including nutrition and IV fluids. At all times, patients must be given basic humane, compassionate care. They should be given a comfortable bed, human contact, warmth, and be kept as free from pain and suffering as possible. While some believe that food and fluids are part of the bare minimum of humane treatment, both are still considered medical treatments. Several court cases have established that it is justifiable to withhold or withdraw food and fluids.
It is rarely justifiable to discontinue life-sustaining treatment for cost reasons alone. There are rare situations in which costs expended on one terminally ill patient could be clearly better used on another, more viable patient. Even so, such decisions must be carefully considered, and made with the full knowledge of patients and their surrogate decision makers (Braddock 5).
The example patient is being treated at the HIV treatment center, and his cancer has metastasized. Patients with metastatic cancer often suffer from profound cachexia, attributable to their inability to get adequate caloric intake from eating alone and the metabolic effects of their cancer. total parenteral nutrition (TPN) is able to provide protein as well as nonprotein nutrients to reverse the catabolic effects of illness. TPN has a number of potential complications, such as those related to infection from the central line catheter site.
In this case, the goals of therapy must be carefully evaluated, as they relate to TPN. Is TPN likely to offer the patient any benefit? If life expectancy can be prolonged with additional chemotherapy,…[continue]
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