Tag: do not resuscitate orders

Bioethics Blogs

Virginia Legislature May Adopt Texas Futility Law

Earlier this year, the Virginia Joint Commission on Health Care (comprised of 18 legislators) was tasked with studying the current legal and regulatory environment on life-sustaining medical treatment, particularly legal requirements regarding disagreements over medical appropriateness. 

The JCHC determined treatment decision conflicts to be frequent.  Data collected in July and August 2016 show 274 cases with ethics committee involvement from 44 reporting hospitals over the past year (roughly 6 per hospital per year).  93% were resolved through consensus, agent replacement, transfer, or death.

In September, a broadly representative JCHC working group made several recommendations for legislative changes that would make Virginia law much like Texas law.  I am delighted to see several of my articles cited in the report.  But I have submitted comments sharing my concerns about the fairness and due process problems with the Texas mechanism.    

Public comments on the proposed options are due to JCHC by September 28.  The comments will be considered by the JCHC at its October 5 meeting.

The complete list of recommendations is:

1. Require hospitals to maintain written policies on life-sustaining treatment decision conflict resolution procedures
2. Require hospitals to take standard minimum steps in cases of life sustaining treatment decision conflict
3. Provide qualified permission to physician to cease inappropriate treatment after 14 days
4. Provide physician immunity for following requirements
5. Stipulate that all actions under this section must conform to federal non discrimination standards
6. Revise “life-sustaining care” term and definition
7. Eliminate Durable Do Not Resuscitate Orders from applicable documents within § 54.1-2990

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.

Bioethics Blogs

A DNR Tattoo Is Not a POLST

It is a trend now to get do not resuscitate orders tattooed onto one’s body.  But these tattoos are not legally recognized.  Clinicians are not authorized (much less required) to honor them.  If you are frail or terminally ill and do not want to be resuscitated, get a POLST.

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.

Bioethics Blogs

Unilateral Do Not Resuscitate Orders

Meredith Miceli, an Associate General Counsel for the Ochsner Health System in New Orleans, published an article in the summer 2016 Ochsner Journal: “Unilateral Do Not Resuscitate Orders.”


Ms. Miceli observes that Louisiana has no legal process like the 1999 Texas Advance Directives Act that offers safe harbor legal immunity.  Indeed, she notes there is “no legal guidance” in Louisiana.  (But the 1998 Causey case might suggest some  caution.)


“So, what  should an attending physician do when, in his or her professional judgment, any clinical treatment other than comfort care will be ineffective or harmful to a patient, but the family’s wishes . . . are in support of doing everything?”


Ms. Miceli advises that “a physician can act to validate his or her opinion on the appropriateness of the DNR order by obtaining the opinion of another physician, and . . . the latter’s signature on the DNR order as well as on an explanatory progress note . . . .”

“This 2-physician signoff process will serve to confirm the medical decision-making . . . and help protect the attending physician from claims of unsoundness or arbitrariness of decision. This 2-physician signature . . . is a prudent layer of protection . . . .”

This process does not provide what many providers crave in these situations: the elimination of uncertainty and risk.  But Miceli is right.  The fairer the internal process, the more likely it will receive deference and respect by external reviewers like a judge or jury.  

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.

Bioethics Blogs

The Ethics of Resuscitation

A Brief History and Center for Practical Bioethics’ Efforts to Improve CPR Outcomes

Promise and Problems

Cardio-pulmonary resuscitation has offered food-for-thought for philosophers and bioethicists from its beginning, and the Center for Practical Bioethics has a long history of grappling with this subject.

In 1966, the National Academy of Sciences reported that closed chest cardio-massage and CPR should be ordinary treatments for hospitalized patients. Before that, CPR was a “hit-and-miss” proposition. Through the 1970s and 80s, the use of CPR became more prominent in hospitals, and CPR expanded to include defibrillation. In 1984, the year the Center was incorporated, Johns Hopkins Hospital became the first to incorporate automated external defibrillators (AEDs) into resuscitation efforts.

CPR was original intended for those who experienced cardiovascular arrests that were witnessed (i.e., those who died of a heart attack observed by someone with CPR skills). By the late 1980s and early 90s, it was being applied to all those who died in hospitals – and raising questions. One writer referred to it as “medical creep.” Another said, “Resurrecting the dead became medicine’s obsession.” Another referred to death itself as a “recurrent problem.”

DNR Orders

The Center for Practical Bioethics and others imagined that issuing do not resuscitate (DNR) orders would protect patients, who had little to no chance of benefiting from CPR, from the harms that can result when CPR is used inappropriately. Typical among these harms are broken ribs, burned skin, massive bruising, and being caught between life and death with little “quality of life.” Ron Stevens, MD, then head of Oncology at the University of Kansas, said that CPR was the “least aesthetically pleasing intervention done in medicine.”

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.

Bioethics Blogs

The Wrongness of Do Not Resuscitate Orders Being Ignored

Guest Post by Joseph Bowen

Joseph is a BPhil Student studying at Oxford University.

Following a surprise inspection of Colchester General Hospital by the Care Quality Commission (CQC) on Friday 14th November, it was reported that inspectors had found that some patients (“elderly people, some [suffering from] dementia”) had been inappropriately restrained, and/or sedated without consent, and that ‘Do Not Resuscitate’ (DNR) notices were being disregarded. What struck me about this case is that, while all are horrible practices, the DNRs being ignored seemed worse than the inappropriate restraint and sedation without consent.

To begin with I would like to say that this post does not seek to condemn any of the staff’s actions all things considered; sitting in front of my computer now, I cannot even begin to imagine the pressure of working in an A&E and/or any other hospital ward – let alone an oversubscribed A&E ward as the CQC’s report found. That said, I am interested as to what’s behind my reaction to this case.

A DNR instructs health care professionals to withhold ‘Cardiopulmonary Resuscitation’ (CPR) and ‘Advanced Cardiac Life Support’ (ACLS) (and ‘Intubation’, where a tube is inserted into the windpipe to maintain an open airway, sometimes additionally indicated by DNI) were a patient’s heart to stop or were the patient to stop breathing. Where DNRs are sometimes understood as an ‘omission of action’ by patients and their families, some propose changing the term to the less emotively-charged ‘Allow Natural Death’. The DNR notice is brought about following a dialogue between the patient, their families, and healthcare professionals; where a patient cannot be involved in discussions it can be mandated by the patient’s family (more specifically, following recent changes, their ‘Health and Welfare’ power of attorney).

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.