1. Sarah E. Shannon, PhD, RN To the Instructor:
This Power Point presentation is a suggested slide presentation that can be used for lecture. It was created from the information in Instruction Material/ Content section of the TNEEL CD-ROM. If the presentation includes some audio sound and video clips, click the red button to play the sound or video.
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Sarah E. Shannon, PhD, RN

2. History of CPR & DNR Orders
The “Birth” of CPR
First study in 1960 found 80% success rate.
Consent presumed.
AMA call for written DNR orders by 1974.
Defining 1976 events:
Karen Ann Quinlan Supreme Court ruling.
Massachusetts General and Beth Israel Hospital formal guidelines published.
First Natural Death Act passed in California.
Cardiopulmonary resuscitation (CPR) initially boasted a success rate of 80% in At that time, patient consent to CPR was initially presumed since consent to other emergency care traditionally has been presumed. However, by 1974, the AMA was calling for written do-not-resuscitate (DNR) orders. In 1976 three events occurred to change the view that CPR should routinely be attempted at the time of death.
Supreme Court of New Jersey ruled that Karen Ann Quinlan could have mechanical ventilation withdrawn;
Massachusetts General Hospital and Beth Israel Hospital published formal guidelines on limiting treatment at the end of life; and
California passed the first Natural Death Act.

3. Current Status of CPR & DNR Orders
More recent studies show success rates for in-hospital CPR of 19%-57%.
DNR, Code Blue, DNAR orders, etc. are more common.
1995 Study: Only 13% of hospitalized patients have CPR attempted at time of death.
Success rates of in-hospital CPR will increase as number of attempts drop.
Success Rates and Utilization
Multiple studies have found in-hospital CPR success rates between 19% to 57% with only 4% to 24% of patients who receive CPR discharged alive.
Many factors led to widespread use of DNR orders to avoid needless or futile resuscitation at the time of death.
A large multi-site study found that only 13% of patients who are hospitalized have resuscitation attempted at time of death. This figure represents approximately 1 in 10 ICU patients receiving CPR at the time of their death. Patients who have CPR attempted are more likely to have an underlying cardiac diagnosis, which is associated with a greater likelihood of success from CPR, thus suggesting that the rate of CPR attempts is appropriate.
As the number of "attempts" decrease, it is important to realize that the "success" rates of in-hospital CPR will increase.
Instructor Note: Consider illustrating this by showing students how changing the denominator from 100 to 50 will double the success rate even when the numerator (the number of successful codes) stays relatively low – say 10.

4. CPR: Legal and Ethical Issues
Does CPR require consent?
Can a patient refuse CPR?
Is CPR a treatment or a right?

5. Legal Basis for Performing or Withholding CPR
CPR falls between the cracks in terms of anticipated treatment for which we would obtain informed consent and emergency treatment where informed consent is presumed.
Obtaining informed consent necessitates dialog about death and dying which may be difficult for providers, patients and surrogates.
DNR orders are generally regulated by informed consent legislation, but patient preferences (as in an advance directive) may also need to be considered.
CPR performed against a patient’s wishes can potentially result in legal problems for providers.
Legal Basis for Performing or Withholding CPR
CPR falls between the cracks in terms of anticipated treatment, for which there is a clear need to obtain informed consent, and emergency treatment where informed consent is presumed.
Obtaining informed consent for CPR necessitates a discussion about death and dying which may be difficult for healthcare professionals and patients or surrogates to have.
DNR orders fall under the informed consent legislation generally and may be informed by the patient's previously stated preferences such as an advance directive.
CPR performed against the patient’s or family’s expressed wishes can result in charges of assault, battery, malpractice or all three for providing an unwanted therapy. Two recent suits brought by families were successful initially and now are being reviewed by appellate courts.

6. Current Issues: DNAR Orders
Many institutions are now using the term Do-Not-Attempt-Resuscitation (DNAR) instead of Do-Not-Resuscitate (DNR)
The word “Attempt” is intended to emphasize that CPR is often not successful
DNAR orders
Recently, many institutions changed the name of no-code orders from do-not-resuscitate orders (DNR) to do-not-ATTEMPT-resuscitation (DNAR) orders. The word “attempt” is intended to emphasize that CPR is often not successful.
DNAR X
DNR

7. Current Issues: “Slow Codes” Definition I
Not responding efficiently or urgently to a code situation thus “going through the motions,” but without meeting the standard of care for resuscitation attempts.
Slow codes: healthcare providers do not respond efficiently or urgently to a code situation thus “going through the motions” but without meeting the standard of care for resuscitation attempts.

8. Current Issues: “Show Codes” Definition II
Rapidly responding to a code situation but not aggressively pursuing resuscitation efforts thus not meeting the standard of care for resuscitation attempts.
Show codes: healthcare providers rapidly respond to a code situation but do not aggressively pursue resuscitation efforts such as through ineffective or brief chest compressions, knowingly using IV lines that are not patent; etc. Again the standard of care for resuscitation is not met.

9. Current Issues: “Slow Codes” & “Show Codes”
Reasons why “Slow Codes” or “Show Codes” exist:
Providers don’t wish to discuss withholding CPR with a patient or legal surrogate due to cultural, racial, religious, or other differences.
Providers have been unsuccessful in obtaining agreement from the patient or the family to withhold CPR.
Both slow codes and show codes are unethical. They represent fraud because typically institutions bill the patient or an insurance carrier. However, they may be utilized by healthcare professionals because:
They do not wish to discuss withholding CPR with a patient or his or her legal surrogate due to cultural, racial, religious or other differences.
They have been unsuccessful in obtaining agreement from the patient or the family to withhold CPR.
Both codes are unethical and represent fraud because typically institutions bill the patient or insurance carrier.

10. Current Issues: Futility
What if health care professionals believe CPR would be futile?
Is CPR a medical treatment or a right?
Do patients or their families have the right to demand CPR even if medical opinion is that it would not be successful, or produce the desired benefit?
Futility
What if healthcare professionals believe CPR would be futile? Is CPR a medical treatment or a right? Do patients or their families have the right to demand CPR even if medical opinion is that it is not indicated because it would not be successful, or produce the desired benefit? For example, CPR would have a very low probability of producing the desired effect of restoring organ function = quantitative futility, or the individual will not and cannot regain neurological function or meaningful consciousness = qualitative futility.

11. Current Issues: Quantitative Futility Definition
Where research suggests that a therapy will have a less than 1% chance of producing the desired physiological effect; e.g. with CPR, of restoring cardiac function.
Quantitative futility: research suggests that a therapy will have a less than 1% chance of producing the desired physiological effect, e.g., CPR will restore cardiac function.

12. Current Issues: Qualitative Futility Definition
Where personal, professional, or public opinion suggests that while a therapy can achieve a desired effect, it will not produce the desired benefit.
e.g., a situation such as persistent vegetative state (PVS) where CPR is expected to be successful in restoring cardiac function, but the individual will not and cannot regain neurological function or meaningful consciousness.
Qualitative futility: where personal, professional or public opinion suggests that while a therapy can achieve a desired effect, it will not produce the desired benefit; e.g., a situation such as persistent vegetative state (PVS) where CPR is expected to be successful in restoring cardiac function but the individual will not and cannot regain neurological function or meaningful consciousness. Qualitative futility is dangerous in that the definition of what is beneficial lacks any kind of clear societal (or professional) consensus. Hence, hospital policies that address withholding CPR on the basis of futility, generally specify quantitative futility versus qualitative.

13. Current Issues: “Portable” DNR Orders I
About half the US states have legislation providing for out-of-hospital or "portable" DNR orders.
Portable DNR orders allow EMS personnel to not start CPR, but allow them to provide . . .
assessment
assistance with choking including airway clearance
oxygen and medications for dyspnea
aggressive pain management
grief counseling
other appropriate services to patient and family
"Portable," Community-based, or Out-of-hospital DNR Orders
1.About half the fifty states in the US have passed legislation allowing out-of-hospital or “portable” DNR orders.
2.If the person with a portable DNR order should arrest, and emergency medical personnel respond, the EMS personnel are allowed not to initiate CPR. However they can provide:
assessment
assistance with choking including airway clearance
oxygen and medications for dyspnea
aggressive pain management
grief counseling
other appropriate services to patient and family

14. Current Issues: “Portable” DNR Orders II
Some states limit to only terminal or elderly patients, others allow for any competent adult.
Both the health care provider’s signature and the patient’s or surrogate’s signature is required.
Patients receive a copy of the original order and also some form of wearable identification.
Most states allow EMS personnel to by-pass the DNR order if the patient’s family strongly insists.
3.Some states limit access to portable DNR orders to patients who are terminal or elderly while other states allow access to any competent adult.
4.Portable DNR orders require both the healthcare provider’s signature and the patient’s or surrogate’s signature.
5.Patients receive two forms of “proof” of this order - a copy of the original order form and a form of “wearable” identification such as a medic alert bracelet.
6.Most states include a provision allowing EMS personnel to perform CPR if the family persistently and strongly requests it even if the person has a portable DNR order. However, EMS personnel are trained to counsel families in these difficult situations to forego CPR.

15. Current Issues: “Portable” DNR Orders III
Ideally the provisions and expectations of a portable DNR order are discussed in an in-patient setting.
Many states are working to make the portable DNR order the standard for nursing homes and other community-based care facilities so that medics who respond to calls in those facilities can honor them.
A portable DNR order is not an advance directive. It is a physicians order to withhold a therapy and requires the patient’s signature as proof of informed consent.
7.Ideally, hospitals, clinics and other healthcare systems have policies that discuss the circumstances under which community-based DNR orders will be honored in the in-patient setting. In particular, policies should address care of the person with a portable DNR order in the emergency room, in the clinic setting, on admission to the hospital, etc. In addition, consideration of the need or desire for a portable DNR order should be part of the nursing discharge assessment for every hospitalized patient.
8.Many states are working to make the portable DNR order the standard for nursing homes and other community-based care facilities so that medics responding to calls in those facilities can honor DNR orders in these facilities.
9.Finally, a portable DNR order is not an advance directive. It is a physician’s order to withhold a therapy and requires a patient/surrogate signature as evidence that informed consent occurred, similar to consent for a surgical procedure.

16. Systems Issues I
Policies that protect a patient’s right to accept or refuse CPR should be written to include provision for:
DNR orders to follow patients across settings/services.
Patients or legal surrogates to be informed when a DNR order is written.
An appeal process in case the physician in charge is unwilling to write the DNR order.
Policies that recognize portable or community-based DNR orders in specific situations or settings.
Hospitals and other institutions and community-based services should have written policies to protect patients’ rights to accept or refuse CPR in advance of an arrest. These policies should include mechanisms to ensure that:
DNR orders follow the patient across settings and services.
Patients or their legal surrogates are informed when a DNR order is written.
Patients and surrogates who request a DNR order have a mechanism to appeal if the physician in charge is unwilling to write the order.
Policies honoring portable or community-based DNR orders in specific situations or settings.

17. Systems Issues II
Hospital policies should allow patients or their surrogates to refuse CPR even in the absence of a written or verbal order from a physician, in cases where:
The patient or their surrogate clearly refuse CPR.
The provider has no evidence to suggest that the request is not made in good faith.
The physician cannot be reached or refuses to write a formal DNR order in spite of the patient’s or surrogate’s wishes.
Hospital policies should also allow patients or their surrogates to have their right to refuse CPR honored even in the absence of a written or verbal order from a physician to withhold CPR. While these are rare situations, they do occur. For example, the nurse or a supervisor, should be able to authorize DNR status in situations where:
the competent patient or surrogate of an incompetent patient clearly refuse CPR in the event of an arrest;
the nurse has no evidence to suggest that this request is not made in good faith (e.g., that the person speaking for the patient is not the valid surrogate); and
the physician cannot be reached to obtain a formal DNR order or the physician refuses to write such an order in spite of the patient’s or surrogate’s lack of consent for CPR procedures.

18. Systems Issues III
Although situations like these are rare, if CPR is administered in spite of a patient’s clear refusal, it may constitute assault and/or battery.
Although situations like these are rare, if CPR is administered in spite of a patient's clear refusal to consent to the therapy, it may constitute assault and battery on the part of the healthcare professional. Institutional policy should address these rare circumstances to ensure that patients do not receive unwanted therapies and that healthcare professionals are not placed in a situation where they must choose between placing themselves at legal or professional risk versus administrative or institutional risk. Some considerations for these policies include but are not limited to:
Requiring that nurses, respiratory therapists, and other non-MD healthcare personnel get witnesses and document in the chart the patient's refusal of CPR.
Initiating vigorous efforts to contact the physician and other appropriate supervisory personnel but ensure that the patient is not subjected to CPR if he/she arrests prior to the order change.
Allowing documented refusals of life-supportive therapies by competent patients to be honored should that patient become incompetent, even in cases in which families insist on providing them.

19. Patient Care Scenarios
Types of Patients with DNR orders
The Classic Scenario
The Critical Care Scenario
The Patient Autonomy Scenario
Community-based or Portable DNR Scenario

20. The Classic Scenario I The “Comfort Care Only” patient
Death is anticipated
Goal: Alleviate suffering
CPR and other treatments withheld
The Classic Scenario: The "Comfort-Care Only" Patient
Features:
Death is anticipated this hospitalization or soon after discharge.
The medical goal of care has switched from one of treating the disease in hopes of prolonging life or "cure" to one of alleviating suffering and not prolonging the dying process.
Therapies have been limited to those that promote comfort. In particular, diagnostic testing and treatment of deteriorating physiological function is being withheld or withdrawn.
CPR is one of many emergency therapies being withheld. The process of pulling back often will have started with a DNR order, followed in quick succession by a withdrawal of other life-sustaining therapies such as mechanical ventilation, blood transfusions, etc.
Nursing personnel are typically most familiar and comfortable with patients represented by this scenario.

21. The Classic Scenario II
The “Comfort Care Only” patient
DNAR does NOT mean "no care"
DNAR, not abandonment
CPR may or may not be futile
Concerns:
Comfort-Care Only DOES NOT mean that a patient should have nutrition and hydration, treatment of yeast infections, symptom management such as treatment of fever, or pain management routinely withheld or withdrawn. There continues to be well-documented evidence that at least half of conscious dying persons experience moderate to severe pain in the last three days of life. More disturbingly in the face of such dismal findings, nurses do a better job providing pain management than treating other sources of suffering such as dyspnea, thirst, hunger, itching, anxiety, etc.
Comfort-Care Only should not constitute an abandonment of the patient and/or family.
CPR itself may not be futile but the condition or prognosis is futile in that physical deterioration cannot be reversed or that the reversal is not desired by the patient or, in the case of a mentally incapacitated patient, by the surrogate.
This “Comfort-Care Only” patient typically presents with a diagnosis that is medically considered terminal (such as widely metastatic cancer, liver failure). The patient is clearly approaching death as evidenced by clinical signs such as anorexia, significant loss of weight, ascites, jaundice, waning consciousness, extreme fatigue, irregular pulse, etc. Often these patients have been admitted because of an overwhelming illness or injury, an unexpected change in a chronic condition for which additional care was sought, a symptom which cannot be managed adequately as an out-patient, or for a palliative care procedure such as insertion of an indwelling line to facilitate medication administration.
Mr. Williams
Family members ask if signing a DNR means the nurse and hospital are giving up on their father

22. The Critical Care Scenario I
The “Do Everything BUT CPR” patient
Reasonable hope of recovery
Goal: Prolonging life, etc.
CPR withheld, but nothing else
The Critical Care Scenario: The "Do Everything BUT CPR" Patient
Features:
Death may occur but there is reasonable hope for a recovery.
The medical goal of care is prolonging life, restoring function, avoiding or minimizing disability, AND alleviating suffering.
Aggressive therapy is being employed in the hopes of "turning the patient's condition around." An example would be a patient with generalized sepsis who is receiving aggressive support for multi-organ failure (e.g., mechanical ventilation, fluid resuscitation, inotropic support, hemodialysis, etc.) and treatment of the septic source (e.g., surgery, drainage, antibiotics, etc.).
CPR is being withheld because if the patient should progress to a cardiac or respiratory arrest, there are no additional therapies that could be employed making survival from an arrest very unlikely.

23. The Critical Care Scenario II
The “Do Everything BUT CPR” patient
Need to reassess situation often
DNAR, not "slow care”
CPR may or may NOT be futile
Concerns:
The medical goal of care should be reassessed at frequent intervals in light of the patient's condition and response to therapy.
The DNR order should not be assumed to affect the aggressiveness or timeliness of medical and nursing care such as diagnostic testing, pulmonary toilet, treatment of fever, pain management, etc.
These patients are at risk for “labeling” as a “no code” patient and thus receiving inadequate care by nursing staff in particular concerning continued aggressive management of physiologic instability and treatment of the underlying cause of disease.
The DNR order may or may not be written on the basis of futility. The determination of futility may apply to the patient's overall condition or prognosis, OR to CPR specifically.
This “Do Everything BUT CPR” patient typically presents to the acute care institution following an acute illness, injury or exacerbation of an underlying condition. For example, a patient with heart disease who experiences a sudden heart attack, a patient who develops sepsis secondary to an infection, or a patient who has suffered trauma. This patient has probably been in the ICU for at least 48 hours receiving maximal aggressive care. Yet, the patient has continued to be unstable. The prognosis for the patient is uncertain but the risk of death is high due to the severity of the patient’s condition.

24. The Patient Autonomy Scenario I
The “Do Only What I Wish” patient
Death may or may not be expected even in the near future
Goal: Will vary with patient
CPR is not wanted
The Patient Autonomy Scenario: The "Do Only What I Wish" Patient
Features:
Death may or may not be expected this hospitalization or in the near future. The patient may or may not have any condition putting him/her at increased risk of suffering a cardiac or pulmonary arrest.
The medical goal of care may be prolonging life, curing disease, restoring function, alleviating suffering, or any combination of those goals.
Other therapies may be provided or may be limited also per the patient's wishes.
CPR is withheld because the patient does not wish to receive it regardless of the possibility of its success. Situations might include an older patient who wishes to "let nature take its course" if he should suffer a heart attack or stroke unexpectedly while in the hospital. Or a young nurse who has seen enough "bad" codes that she has decided that under no circumstances--even those that might be reversible--would she wish to receive CPR. Or, the cancer patient admitted for a palliative operation where death is not expected this hospitalization but who wishes to ensure that he/she is not resuscitated under any situation even if it were unrelated to the diagnosis of cancer and potentially reversible.

25. The Patient Autonomy Scenario II
The “Do Only What I Wish” patient
“No CPR" means ONLY “No CPR”
Need to clarify patient's wishes
CPR may or may not be futile
Concerns:
Extreme caution needs to be taken not to extrapolate the patient's wish regarding no CPR to other therapies that are desired by the patient such as antibiotics, pain management, aggressive diagnostic workups, chemotherapy, etc.
Care providers need to guard against misunderstandings about the patient's wishes regarding general aggressiveness of care leading to mistreatment and undertreatment.
Care providers' need to clarify the CPR order under special circumstances such as surgery.
The DNR order may be written on the basis of futility but the determination of futility is specific to the CPR only, not the overall care of the patient.
This “Do Only What I Wish” patient does not present in any typical manner. The patient may be hospitalized for a routine procedure (such as a coronary bypass graft), a minor illness (such as diverticulitis) or another reason. The patient has considered the prospect of CPR should he/she experience a cardiac or respiratory arrest and has decided to forego resuscitation attempts. The patient’s views may appear idiosyncratic or well thought-out, logical or silly, appropriate to the patient’s overall state of health or premature. After carefully assessing the basis for the patient’s wishes regarding CPR, a patient who appears to be competent and who is making an informed choice has the right to refuse a recommended medical therapy. Exceptions to this right might be covered by hospital policy and include the intra-operative period or during certain procedures such as an angioplasty.

26. Community-based or Portable DNR Scenario I
The “Help Me but Don’t Save Me” patient
Death may or may not be expected even in the near future
Goal: Will vary with patient
CPR is not wanted
Community-based or Portable DNR Scenario: The “Help Me But Don’t Save Me” Scenario
Features:
Death may or may not be expected this hospitalization or in the near future. The patient may or may not have any condition putting him or her at increased risk of suffering a cardiac or pulmonary arrest.
The medical goal of care may be prolonging life, curing disease, restoring function, alleviating suffering, or any combination of those. However, often these patients will have chosen to forego further aggressive medical care such as hospice patients.
Other therapies may be provided or may be limited also per the patient's wishes. If EMS personnel are called, they can provide aggressive management of pain or other symptoms but are not obligated to provide CPR in the event of an arrest.
CPR is withheld because the patient does not wish to receive it generally in light of their underlying health condition.
A community-based No CPR order requires the signature of the patient or the legal surrogate and of the physician.

27. Community-based or Portable DNR Scenario II
The “Help Me but Don’t Save Me” patient
Requires signature of patient or patient’s surrogate and physician
“No CPR" means ONLY “No CPR”
Need to clarify patient's wishes
CPR may or may not be futile
Concerns:
Extreme caution needs to be taken to not extrapolate the patient's wish not to receive CPR to other therapies that ARE desired by the patient such as assistance with choking, pain management, etc.
Care providers need to guard against misunderstandings about the patient's wishes regarding general aggressiveness of care leading to mistreatment or undertreatment.
Care providers' need to clarify the CPR order under special circumstances such as surgery or admission to an acute care facility.
The community-based DNR order may be written on the basis of futility.
This “Help Me But Don’t Save Me” person (or their legal surrogate) will have obtained a community-based DNR order from his/her usual physician. Typically, these patients have end-stage organ failure (e.g., heart, lung), a terminal cancer diagnosis, liver failure, end-stage AIDS, Alzheimer’s disease, or other serious conditions where death is expected in months to years. A “terminal” diagnosis is not required, however. In many states, there is no technical barrier to any adult obtaining a community-based DNR order. However, in practice physicians act as gatekeepers, ensuring that persons who have obtained these orders have made an informed decision.