Chapter 25 - Guidelines For Withholding Cardiopulmonary Resuscitation

3-25.1  INTRODUCTION

1. PURPOSE.  This chapter establishes the Indian Health Service (IHS) policy regarding guidelines for withholding cardiopulmonary resuscitation (CPR) for certain patients.
2. BACKGROUND.  The IHS remains committed to the principle of supporting and sustaining life by using the latest life-saving or life-supporting techniques and therapeutic measures when medically appropriate.  Medically appropriate care at the end of life always should benefit the patient and never merely prolong the dying process.  Moreover, full consideration will be granted to patients regarding their wishes to accept or refuse medical interventions.
3. POLICY.  All patients shall be presumed as having consented to cardiopulmonary resuscitation unless there is documentation in the medical record indicating the contrary.  Unless a "Do Not Resuscitate (DNR)" order is present in the medical record, hospital and clinic staff will initiate resuscitation in the event of cardiac or respiratory arrest except in a medically futile situation.  This policy applies to all IHS hospitals.
4. DEFINITIONS.
   1. Attending Physician.  The physician or other duly licensed and privileged member of the medical staff having primary responsibility for the treatment and care of the patient.  This includes cross-covering medical staff.
   2. Cardiopulmonary Resuscitation.  The administering of any means or devices intended to restore or support cardiac and/or pulmonary function in a patient by means of ventilatory assistance (manual or mechanical), cardiac massage, chest compressions, cardioversion, administration of pharmacological agents, or other procedures when cardiac or respiratory arrest has occurred or is believed to be imminent.
   3. Code Status.  The plan of care in the event that cardiac or respiratory arrest has occurred or is believed to be imminent.
   4. Do Not Resuscitate Order.  An order that is entered or cosigned by the attending physician into the patient's medical record that states the patient will receive all medically appropriate therapeutic and/or palliative care, but in the event the patient suffers cardiac or respiratory arrest, CPR will not be attempted.  The DNR order may be written to Provide for limited or modified CPR efforts in accordance with the patient's or surrogate's wishes.
   5. Patient With Decision-making Capacity.  A person of legal age of majority as defined by the law of the State or Tribal jurisdiction in which the health care facility is located, who is:
      1. conscious,
      2. able to understand the nature and severity of his/her illness and the consequences of and alternatives to the proposed treatment, and
      3. able to make informed and deliberate choices concerning the course of treatment.
   6. Patient Lacking Decision-making Capacity.  A person who:
      1. is not of legal age of majority, as defined by the law of the State or Tribal jurisdiction in which the health care facility is located;
      2. is unconscious;
      3. is unable to understand the nature and severity of his/her illness and the consequences of and alternatives to the proposed treatment, or is otherwise unable to make informed and deliberate choices concerning the course of treatment; or
      4. has been declared legally incompetent by a court.
   7. Surrogate.  The patient's legal guardian or other person authorized to make health care decisions on the patient's behalf under the law of the State or Tribal jurisdiction in which the health care facility is located.  If no surrogate is identified, then the responsibility falls to a competent adult who has been identified as most likely to know the wishes of the patient and act in the patient's best interest with respect to the possible withholding or withdrawal of medical treatments.

3-25.2  PROCEDURES  Any reference to "hospital" or "hospitals" herein shall be construed to encompass all IHS health care facilities that admit patients for inpatient care.  This section pertains specifically to the inpatient setting.

1. THE PATIENT WITH DECISION-MAKING CAPACITY.
   1. When the patient requests a DNR order or otherwise provides instructions to limit CPR, the attending physician shall write an order in the patient's medical record specifying the code status requested and document the discussion in the patient's medical record.
   2. When the attending physician determines that resuscitative efforts would not be indicated because they would provide no benefit to the patient, the attending physician must discuss the rationale for a proposed DNR order with the patient.  All discussions must be clearly documented in the patient's medical record.  If the patient requests that a DNR order not be entered, or instructs that CPR be instituted, no DNR order shall be entered by the attending physician even if this is contrary to the attending physician's advice. However, CPR need not be administered in situations governed by Section 3-25.2G.
   3. If the patient requests that family not be involved in or informed of a decision regarding whether or not to enter a DNR order, the patient's decision and request for confidentiality shall be documented in the medical record by a staff member who is not a member of the treatment team; e.g., a patient advocate or ombudsman.  However, in all other situations, discussion between the attending physician and the patient's family should be pursued to ensure an understanding of the basis for and the consequences of any order to limit (or not limit) CPR.
2. THE PATIENT LACKING DECISION-MAKING CAPACITY WHO HAS A SURROGATE.
   1. When the patient has an advance directive that clearly stipulates the patient's preference for a DNR order or otherwise provides instructions for limiting (or not limiting) CPR, the attending physician shall make every effort to honor that preference. Discussion between the attending physician and the patient's surrogate and family should be pursued to ensure an understanding of the basis for and the consequences of any order to limit (or not limit) CPR.
   2. When the patient has no advance directive, the surrogate generally will have responsibility for establishing code status. Discussion between the attending physician and the surrogate should be pursued to establish that the request is consonant with the patient's expressed values and that it addresses the balance among relief of suffering, preservation of life, the likelihood of restoration of function, and the quality and extent of sustained life.
   3. When the attending physician determines that CPR would not be indicated because it would provide no benefit to the patient, the attending physician must discuss the rationale for a DNR order with the surrogate (and, when possible, the family).  All efforts must be made to assist the surrogate (and when possible, the family) to understand the basis for and the consequences of a DNR order.  The discussion should be documented in the patient's medical record.  If the surrogate requests that a DNR order not be entered, or instructs that CPR be instituted, no DNR order shall be entered by the attending physician even if this is contrary to the attending physician's advice.  However, CPR need not be administered in situations governed by Section 3-25.2G.
3. THE PATIENT LACKING DECISION-MAKING CAPACITY WHO DOES NOT HAVE A SURROGATE.
   1. When the patient has an advance directive that clearly stipulates the patient's preference for a DNR order or otherwise provides instructions for limiting (or not limiting) CPR, the attending physician shall make every effort to honor that preference.
   2. When the patient does not have an advance directive or surrogate and the attending physician determines that CPR would not be indicated because it would provide no benefit to the patient, the decision must be reviewed according to an established review mechanism (See Section 3-25.2D).  Written documentation of the decision upon review should be placed in the patient's medical record.  Reviews must be conducted as expeditiously as possible (preferably within 48 hours after the attending physician makes the determination that CPR is not indicated).  While review proceedings are taking place, CPR should not be withheld except in situations governed by Section 3-25.2G.
4. REVIEW MECHANISM.  A review mechanism should be established to consider any disagreements among staff, between staff and a patient, or between staff and a patient's surrogate or family members in regards to DNR orders.  Potentially effective review mechanisms include, but are not limited to, peer review by a neutral senior physician or other senior medical staff, consultation with the medical staff executive committee, and/or review by an institutional ethics committee.
5. PERIODIC REVIEW OF CODE STATUS.  Code status should be reviewed at regular intervals and in the event of significant clinical changes or upon the patient's or surrogate's request.  Progress notes should document daily the clinical condition of the patient.
6. DOCUMENTATION.  All DNR orders or orders otherwise limiting CPR should be written or cosigned by the attending physician.  Documentation in the patient's medical record should contain at minimum the following information:
   1. The patient's medical condition and prognosis;
   2. an assessment of the patient's mental status and decision-making capacity;
   3. the presence or absence of advance directives, and if present, the wishes expressed therein; and
   4. documentation of discussions with the patient or surrogate and the patient's family concerning the patient's condition and the basis and consequences of withholding CPR and the decision reached.
7. MEDICALLY FUTILE SITUATIONS.  In a situation in which the attending physician determines in his or her judgment that CPR would be clearly and obviously futile, CPR may be withheld.  Whenever possible, the attending physician should obtain the concurrence of a second (neutral) physician that CPR may he withheld because it would be clearly and obviously futile.
8. TRANSFER OF CARE TO ANOTHER PHYSICIAN.  Attending physicians who conclude, in good conscience and sound medical judgment, that they are unable to comply with the wishes of the patient (or surrogate) concerning the administration (or withholding) of CPR, shall arrange to transfer care of the patient to another physician who is capable of appropriate and skilled care and who is able to comply with the patient's (or surrogate's) wishes.
9. RELATED MEDICAL CAFE.  Do not resuscitate orders are compatible with maximal therapeutic efforts other than CPR.  A patient for whom a DNR order has been entered is entitled to receive vigorous support in all other therapeutic modalities.
10. DISCUSSIONS.  All discussions described herein with the patient, surrogate, and/or family shall be conducted with utmost attention to privacy and confidentiality.
11. LEGAL CONSULTATION.  The hospital administration should be informed in any case where legal advice is being considered.
    1. When the patient falls within one of the categories listed below, a DNR order should not be written without consultation with an appropriate attorney in the Office of the General Counsel:
       1. The patient is pregnant,
       2. the patient is a victim of a crime or suicide attempt, or
       3. the patient's condition is possibly a result of medical error.
    2. Legal consultation also should be considered when:
       1. there is an unresolved family disagreement over the writing of a DNR order, or
       2. questions arise concerning the applicability of natural death statutes (e.g., State or Tribal laws regarding advance directives).