When DNR is a Non-choice Choice

A seventy year-old gentleman presented to our hospital for elective descending thoracic aortic aneurysm repair.

Story from the Frontlines

Four years earlier, the patient suffered acute aortic dissection of the descending aorta and was effectively treated with tight blood pressure control. This dissection was followed with serial imaging and his aorta slowly expanded to 6.5 cm. The patient reported intermittent back pain, fatigue and weakness progressing over several months. After extensive discussion with the vascular surgeon and routine cardiopulmonary testing, the patient was brought to the operating room for replacement of his arch and thoracic aorta.

After eight hours of surgery the new aortic graft was in place when the patient suddenly developed acute coagulopathy requiring massive transfusion and vasopressor support. Despite prolonged, aggressive efforts to reverse this non-surgical bleeding, the surgeon was unable to halt the massive hemorrhage; the etiology of the coagulopathy was undetermined. He believed the patient’s death to be imminent and informed the patient’s family. The patient returned to the intensive care unit (ICU) on maximal hemodynamic support.

In the ICU, the treating physician spoke to the patient’s wife. She described it this way to us, “[he] came out and talked to us. And, you know, he had to ask the question, would we want to do CPR?” She asked him if cardiopulmonary resuscitation (CPR) would serve any purpose and he confirmed it would not, given the uncontrollable bleeding; it would only prolong the dying process. Now, three months after her husband’s death, she continues to worry that her decision to withhold resuscitation contributed to his death. She recounts, “And I’ve asked myself that question afterwards, you know. Should I let him go ahead and do the CPR? But, you know, according to their outlook on it, it wouldn’t have changed anything. So I didn’t want to put him through that… It’s the hardest decision I’ve ever made.”

Teachable Moment

Unfortunately the patient experienced an outcome that neither the family nor the surgeon expected. The patient’s death was foretold in the operating room when the surgeon determined the coagulopathy could not be reversed. However, the patient’s death actually occurred in the ICU where institutional guidelines and cultural norms posit CPR as the default option. To support patient autonomy we reflexively ask all patients and/or their families to actively give permission to withhold CPR regardless of its expected effectiveness.

While this patient represents an extreme example of physiologic futility, there are many other patients who similarly would not benefit from attempted CPR including those with metastatic cancer, major trauma or end-stage liver disease.¹ Yet CPR has been the default treatment for all patients since the 1970’s² and patients or surrogates must generally consent to a do-not-resuscitate (DNR) order to restrain medical staff from performing CPR. Offering choices about ineffective treatment (essentially non-choices) to patients and families at the end-of-life harms survivors as they feel accountable for this decision associated with conflict and regret.³ Family members are pressured to make an in-the-moment, life-and-death choice; creating the illusion they have some responsibility for a loved one’s death.⁴

Many hospitals, including our own, have policies that allow physicians to withhold or withdraw treatment in the setting of physiologic futility. However, as we show here, defining futility is fraught with hazard and clinicians are so accustomed to asking patients and/or surrogates to endorse DNR that they fail to recognize situations when CPR is not an acceptable choice. For this patient and for others where CPR is inappropriate a better approach would inform surrogates that CPR will not be performed during the dying process and check for dissent. For example, “We will keep him as comfortable as possible and when his heart stops, we will not attempt to restart it. Does this make sense to you?” This framework would (1) send a message that providers will continue to care for the patient, (2) clarify that the use of CPR is not a treatment that requires deliberation or ownership by the surrogate, and (3) confirm that family members understand that CPR will not be used.⁵ It can readily be adapted to a variety of clinical scenarios.

Honoring patients’ autonomy by helping them to make informed medical decisions is deeply respectful of their right to self-determination. However, presenting CPR as an appropriate treatment option and asking patients or surrogates to chose between CPR and DNR for imminently and irreversibly dying patients does nothing to enhance autonomy and can harm survivors. A more nuanced approach would ease the burden of actively “choosing” to forgo attempts at CPR and still inform patients and families of the expected course.