1. WHAT DOES DNR REALLY MEAN? COMFORT MEASURES ONLY C. Antonio Jesurun, MD Professor of Pediatrics Director of Neonatal Intensive Care June 29, 2005

2. Resuscitation or CPR Medical procedure which seeks to restore cardiac and/or respiratory function to individuals who have sustained a cardiac/respiratory arrest

3. Why All the Concern? Withholding life-sustaining treatment Withholding life-sustaining treatment CMO-Does not mean abandoning the patient CMO-Does not mean abandoning the patient 1983: The President’s Committee for the Study of Ethical Problems in Medicine 1983: The President’s Committee for the Study of Ethical Problems in Medicine “Deciding to Forgo Life-Sustaining Treatment” “Deciding to Forgo Life-Sustaining Treatment”

4. Ethical Principles Autonomy Autonomy Beneficence Beneficence Nonmaleficence Nonmaleficence Justice Justice Truth-telling Truth-telling Promise-keeping Promise-keeping

5. Ethical Issue Analysis 1. Medical Indications 2. Patient preferences 3. Quality of life 4. Contextual features

6. Quality of Life Object of medical intervention is to restore, maintain, or improve quality of life Object of medical intervention is to restore, maintain, or improve quality of life Whose quality is used for judgment? Whose quality is used for judgment? Subject to bias & prejudice Subject to bias & prejudice General measures: mobility, performance of activities of daily living, absence of pain, social interaction, mental acuity General measures: mobility, performance of activities of daily living, absence of pain, social interaction, mental acuity

7. Contextual Issues Should be evaluated in terms of their: Should be evaluated in terms of their: Psychological, emotional financial, legal, scientific, educational, religious impact on patient & others Psychological, emotional financial, legal, scientific, educational, religious impact on patient & others

8. Paternalism The days of the physician making independent decisions are gone. The days of the physician making independent decisions are gone. Today’s standard—self-determinism Today’s standard—self-determinism

9. One Ethical Principle Respect for Autonomy means: Respect for Autonomy means: Self-determination to make choices based on one’s own values & belief system Self-determination to make choices based on one’s own values & belief system Others refrain from interfering with choices Others refrain from interfering with choices Patient free from coercion in deciding to act Patient free from coercion in deciding to act True informed consent True informed consent One should tell the truth One should tell the truth Privacy and confidentiality respected Privacy and confidentiality respected

10. Definition of Death An Individual who has sustained either: An Individual who has sustained either: 1. Irreversible cessation of circulatory and respiratory functions, OR 2. Irreversible cessation of all functions of the entire brain, including the brain stem 1980 Uniform Determination of Death Act

11. Comfort Measures Only Shift of goal from curative to palliative Shift of goal from curative to palliative Therapeutic measures directed towards comfort Therapeutic measures directed towards comfort Excludes specific interventions as listed on “Resuscitative Status Form” Excludes specific interventions as listed on “Resuscitative Status Form”

16. Resolution of Conflicts If irreconcilable w/ moral view-withdraw & provide alternative care If irreconcilable w/ moral view-withdraw & provide alternative care If conflict with generally accepted standards or policies-concern should be voiced to appropriate institutional body If conflict with generally accepted standards or policies-concern should be voiced to appropriate institutional body If this is not possible within time-frame then care should adhere to patient’s directives If this is not possible within time-frame then care should adhere to patient’s directives ASA House of Delegates Oct. 1993. amended 2001

17. Vegetative State Loss of cognitive neurological function and awareness of the environment. Retention of noncognitive function and a preserved sleep-wake cycle. Loss of cognitive neurological function and awareness of the environment. Retention of noncognitive function and a preserved sleep-wake cycle. Sometimes described as when a person is technically alive, but his/her brain is dead. That description is not completely accurate. In a persistent vegetative state the individual loses the higher cerebral powers of the brain, but the functions of the brainstem, such as respiration (breathing) and circulation, remain relatively intact. Sometimes described as when a person is technically alive, but his/her brain is dead. That description is not completely accurate. In a persistent vegetative state the individual loses the higher cerebral powers of the brain, but the functions of the brainstem, such as respiration (breathing) and circulation, remain relatively intact. National Institute of Neurological Disorders and Stroke, National Institutes of Health

18. Decision-Making Competent person Competent person Family Family Court Court Substituted judgment (based on what the patient would have wanted) Substituted judgment (based on what the patient would have wanted) Surrogate (based on what the surrogate believes is right) Surrogate (based on what the surrogate believes is right)

19. Surrogate Decision-Making Hierarchy 1. Legal guardian 2. Spouse 3. Adult children 4. Parents of patient 5. Adult siblings of patient

20. Institutional or Judicial Review No family member wants to be surrogate No family member wants to be surrogate Dispute among family members Dispute among family members Provider does not believe patient would have made specific decision Provider does not believe patient would have made specific decision Provider does not believe decision could be reasonably judged in the patient’s best interest Provider does not believe decision could be reasonably judged in the patient’s best interest AMA Code of Ethics, 150 th edition

21. Ethics Committee To act as a consultant in difficult medical/ethical cases To act as a consultant in difficult medical/ethical cases Forum for open and free discussion Forum for open and free discussion Review of cases involving ethics Review of cases involving ethics Education in Ethics Education in Ethics

22. Approach to Patient Discussion with patient regarding: Discussion with patient regarding: Quantitative likelihood of various outcomes Quantitative likelihood of various outcomes Qualitative aspects of outcomes and meaning to patient & family Qualitative aspects of outcomes and meaning to patient & family Burden of reaching various quantitative and qualitative outcomes Burden of reaching various quantitative and qualitative outcomes

23. Dilemmas-Values in Conflict Conflicting Conflicting Values Values Rights Rights Duties Duties Ethical principles Ethical principles

24. Ethical Principles Autonomy Autonomy Beneficence Beneficence Nonmaleficence Nonmaleficence Justice Justice Truth-telling Truth-telling Promise-keeping Promise-keeping

25. Approach to Comfort Measures Only Sensitivity to the issues Sensitivity to the issues Empathy Empathy Founded in ethics Founded in ethics Familiarity with guidelines & protocols Familiarity with guidelines & protocols Sound communication with patient, family, health-care team Sound communication with patient, family, health-care team