Should a reversible, but lethal, incident not be treated when a patient has a do-not-resuscitate order?

Abstract

Despite the frequency of use of do-notresuscitate orders, there is still uncertainty regarding their optimal use. We discuss a controversial issue concerning end-oflife care arising from two cases from the Office of the Chief Coroner for Ontario: What are the limits of medical therapy for patients who have a critical incident and for whom a do-not-resuscitate order has already been written? CasesCase 1 A 90-year-old woman lived independently, despite a history of stroke, congestive heart failure, emphysema, osteoporosis and hypothyroidism. After a fall in her residence during the winter, she presented to the emergency department of her local hospital where she was given long -acting morphine orally to control pain in her chest wall. With a diagnosis of pneumonia and renal failure, the patient was transferred to a ward, where the morphine was discontinued and hydromorphone was ordered in its place. Unfortunately, the patient received both analgesics. Two days after admission to the ward, she was found unrousable. Narcotic overdose was considered. After a single bolus dose of naloxone intravenously, the patient became alert; however, left alone for a few minutes, she was then found without vital signs. No further attempt at resuscitation was attempted because a do-notresuscitate order had been previously entered in her chart at her request. Case 2A 42-year-old woman who had received a diagnosis of breast cancer was found to have bony metastases four years later, for which she underwent hormonal treatment in conjunction with chemotherapy and radiotherapy. Esophageal stricture developed, and the patient required bougienage 11 and 12 years after the initial diagnosis. The year after the patient's last bougienage, she was admitted to hospital with dehydration, dysphagia and poorly controlled pain. In the emergency department, she received small doses of morphine intravenously. Upon transfer to the ward, the patient was inadvertently given hydromorphone instead of morphine. Shortly thereafter she was found not breathing. Resuscita tion was not performed because of a do-not -resuscitate order on her medical record. DiscussionPhysicians should be familiar with modern principles of end-of-life and palliative care for pa tients with terminal illnesses. Many guidelines have been developed and promulgated by professional societies and regulatory authorities.1 Central to highquality end-of-life care are the discussions physicians are encouraged to have with the patient and family, or substitute decision-maker, regarding the expected prognosis and the patient's wishes concerning end-of-life care. These discussions are particularly appropriate for patients with chronic illnesses and fragility for whom death would not be an unexpected outcome at any point. Resuscitation was originally devised for, and is most successful in, those circumstances where death due to cardiac arrest is unexpected and sudden (e.g., a near-drowning, sudden lethal arrhythmia).3 Cardiopulmonary resuscitation (CPR) subsequently became the default response ...

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