Bioethics Blogs

Do Not Resuscitate – When NOT to Seek Consent

For 45 years, CPR has remained the default treatment for all patients.  Typically, patients or surrogates must consent to a DNR order, to restrain medical staff from performing CPR.  

There are two legal exceptions.  First, clinicians need not seek consent, if CPR would be “physiologically futile.”  Second, at least in Maryland and Vermont, clinicians need not seek consent, if CPR would be “medically ineffective.”  

But what about the grayer zone when clinicians judge CPR to be quantitatively or qualitatively futile?  In JAMA Internal Medicine, three UW-Madison surgeons argue for the following two-step approach:

  1. Inform the surrogate that CPR will not be performed
  2. Check for dissent

The authors argue that this approach:

  1. Confirms that clinicians will continue to care for the patient
  2. Clarifies that CPR is not a treatment that requires deliberation or ownership by the surrogate
  3. Confirms that family members understand that CPR will not be used

Seeking assent beats unilateral or covert action.  The level of transparency recommended by the UW surgeons is what recent courts decisions in the UK (Tracey), Canada (Chapman & Livingstone), and the USA (Marsala) have confirmed is minimally required.  

Still, since these are heavily value-laden and preference-sensitive treatment decisions, I am concerned (though not convinced) that framing CPR as a “non-choice” may not sufficiently respect the patient’s autonomy and right to informed consent.  

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.