Doctors in limbo: the United States ‘DNR’ debate

Lederberg, Marguerite S.

doi:10.1002/(sici)1099-1611(199712)6:4<321::aid-pon289>3.0.co;2-#

Cited by 8 publications

(6 citation statements)

References 37 publications

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“…Although most states simply accept DNR orders as part of standard medical practice, some states, such as New York and Oklahoma, are unusual in having explicit DNR statutes (New York Public Health Law, 1987; Oklahoma Do Not Resuscitate Act, 2005). Under New York state law, resuscitation is legally required unless actively refused by the patient or surrogate (Lederberg, 1997). In addition, for many reasons, including fear of litigation, the vast majority of New York hospitals require a signature from the patient or surrogate should they choose to be DNR despite the fact that the state law only requires a consent (written or verbal) with appropriate documentation (Jezewski & Finnell, 1998).…”

Section: Introductionmentioning

confidence: 99%

The surrogate's experience in authorizing a do not resuscitate order

et al. 2008

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Section: Introductionmentioning

confidence: 99%

The surrogate's experience in authorizing a do not resuscitate order

et al. 2008

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“…A New York law explicitly provided for CPR to be given by default unless actively refused. 79 This law was supported by religious groups with a vitalist philosophy, devoted to preserving physical life, even without quality. Ironically, this law was initiated in an effort to establish the right to refuse CPR, but it evolved into legislation that ensured the preservation of default CPR.…”

Section: Paradigm #1: Cprmentioning

confidence: 99%

“…7 Default CPR creates potential stress for patients and families. 26,57,79 It is emotionally taxing for patients and families to give permission to withhold resuscitation. 79 It is also questionable whether it is morally appropriate to impose logistic obstacles and potential emotional stress on patients and proxies seeking to forgo a the default therapy when the outcome is so likely to be poor.…”

Section: Economics Of Cprmentioning

confidence: 99%

“…26,57,79 It is emotionally taxing for patients and families to give permission to withhold resuscitation. 79 It is also questionable whether it is morally appropriate to impose logistic obstacles and potential emotional stress on patients and proxies seeking to forgo a the default therapy when the outcome is so likely to be poor. 57 Symbolism and psychological issues add additional difficulty to decision making, for example, by implying erroneously that CPR/DNR decisions represent a choice between life and death, even when the true outcome is unlikely to be affected.…”

Section: Economics Of Cprmentioning

confidence: 99%

“…57 Symbolism and psychological issues add additional difficulty to decision making, for example, by implying erroneously that CPR/DNR decisions represent a choice between life and death, even when the true outcome is unlikely to be affected. 26,79 Terms such as do not resuscitate imply that resuscitation would be successful if provided. DNR discussions may unwittingly raise moral questions for decision makers about who deserves CPR, which could, in turn, lead to guilt among family members.…”

Section: Economics Of Cprmentioning

confidence: 99%

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The Ethical and Economic Impact of Defaults

Siegel

Stapleton

Wunsch

2012

Semin Respir Crit Care Med

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Medical care offered to the critically ill often occurs by default, unfolding automatically unless concerted effort is made to do otherwise. In their scope, defaults include traditional approaches to treatment and decision making, as well as policies deliberately set to promote specific health outcomes. Defaults are ethically sound to the extent that they foster patient well-being and autonomy. Unfortunately in practice, some defaults lead to ineffective, unwanted, and expensive care. This article reviews the ethical and economic impact of defaults, paying special attention to their influence on the practice of cardiopulmonary resuscitation and admission to the intensive care unit.

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The Appropriate Use of Increasingly Sophisticated Life-Sustaining Technology

Abrams

Prager

Blinderman

et al. 2013

AMA Journal of Ethics

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The field of medicine has seen significant advances in the ability to support or replace native organ function over the last several decades. Renal hemodialysis, in existence since the 1940s [1], has become standard treatment for patients suffering from end-stage kidney disease and is often used in the outpatient setting as a bridge to transplantation or as a destination therapy, where it permanently replaces organ function [2]. Likewise, continuous venovenous hemodialysis (CVVHD) may be used in the critical care setting for potentially reversible kidney injury, among other indications [3]. Ventricular assist devices (VADs) may partially or completely replace cardiac function; a total artificial heart (TAH) completely replaces it [4], and either one may be used as a bridge to heart transplantation or a destination therapy [5,6]. Liver replacement alternatives, which include the extracorporeal liver assist device (ELAD) and the molecular adsorbent recirculating system (MARS), replaces the detoxification function of a failing liver [7].Extracorporeal membrane oxygenation (ECMO) uses a pump to withdraw deoxygenated blood from a central vein, provide oxygen and remove carbon dioxide via diffusion across a semipermeable membrane, and return oxygenated blood into a central vein or artery, essentially functioning as an external artificial lung, heart, or both [8]. In cases of respiratory failure, ECMO is being used with increased frequency as a supplement to, or occasionally in place of, invasive mechanical ventilation [9][10][11][12]. While this technology has the ability to replace a patient's native lung function, its use, like use of liver replacement therapies and CVVHD, requires ongoing attention in an intensive care unit (ICU). ECMO can serve as a bridge to recovery from reversible illnesses or as a bridge to transplantation for select patients, but not currently as a destination therapy.As organ replacement technologies become increasingly sophisticated and more readily available, we will have the ability to prolong organ function for longer, which raises significant questions about their appropriate use. Appropriate Use of Organ-Replacement Interventions in Individual CasesThe fact that we have the ability to sustain organ function does not mean that it is always medically or ethically appropriate to do so. It is reasonable to base assessment of the medical appropriateness of a technology on the likelihood of its achieving reasonable goals. In the case of these sophisticated organ-replacement technologies, reasonable goals are not only replacing the failing organ but also

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Doctors in limbo: the United States ‘DNR’ debate

Cited by 8 publications

References 37 publications

The surrogate's experience in authorizing a do not resuscitate order

The surrogate's experience in authorizing a do not resuscitate order

The Ethical and Economic Impact of Defaults

The Appropriate Use of Increasingly Sophisticated Life-Sustaining Technology

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