Special Article
Conditional Permission to Not Resuscitate: A Middle Ground for Resuscitation

https://doi.org/10.1016/j.jamda.2019.01.002Get rights and content

Abstract

Every decision to perform or withhold cardiopulmonary resuscitation (CPR) has ethical implications that are not always well understood. Value-based decisions with far-reaching consequences are made rapidly, based on incomplete or possibly inaccurate information. For some patients, skilled, timely CPR can restore spontaneous circulation, but for others, success may either be unobtainable or bring serious iatrogenic consequences. Because CPR is an aggressive process yielding mixed results, patients must be informed about the likelihood of its positive and adverse outcomes. In considering whether to accept or refuse it, patients should also be given a realistic set of alternatives. Current protocols limit patients' options by restricting them to a choice between accepting or refusing CPR. Adding a “middle” code, DNAR-X (Do Not Attempt Resuscitation–Except), significantly expands patients' right to control what happens to their bodies by allowing them to stipulate CPR in some circumstances but not in others.

Section snippets

Potential Benefits and Risks of CPR

CPR has varying success in achieving return of spontaneous circulation. The overall survival rates of CPR range from 2.2% to 9% internationally.8 Although in-hospital rates are higher, survival still ranges only from 15% to 20%.9 Data from the Get With the Guidelines–Resuscitation registry show gradual annual improvement.10 As reported by the Cardiac Arrest Registry to Enhance Survival in 2017, 28.1% of American patients treated in the community survived to hospital admission and 10.4% to

Offering CPR

There are no ethical conflicts in the simplest case, as when a healthy young patient whose preferences are unknown suffers traumatic cardiopulmonary arrest that is witnessed and likely to be successfully reversed through rapid, skillful CPR. However, many cases are not this simple because legitimate arguments can be made to withhold or terminate CPR.

CPR: When Not to Resuscitate

In keeping with distributive justice, providers can decline to offer CPR in various situational circumstances by following a 3-step process: (1)

Conclusion

When used skillfully with appropriate patients, CPR is an invaluable life-preserving process. But as with everything in medicine, benefits may come with offsetting harms that contraindicate its use. Providers need a clear understanding of the potential outcomes and the ethical implications of all aspects of resuscitation. Shared decision making should be used to give patients information about the pros and cons of CPR and other treatment alternatives as part of an effort to help them articulate

Acknowledgments

Mickey Eisenberg, Department of Emergency Medicine, University of Washington, generously suggested resources and edited early versions of this manuscript.

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    The authors declare no conflicts of interest.

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