After a goal oriented conversation, Mrs. W continues to request to be fully resuscitated in the setting of cardiopulmonary arrest. However, several days later, despite a worsening clinical condition, Mrs. W still requests to be a "full code." Your intern suggests that you sign her out as a "slow code." Should you do this?
Mrs. W is an 81-year-old woman with recurrent colon cancer with liver metastases admitted to the hospital for chemotherapy. Because of her poor prognosis, you approach her about a DNR order, but she requests to be "a full code." Can you write a DNR order anyway?
Mr. H is a 24-year-old man who resides in a skilled nursing facility, where he is undergoing rehabilitation from a cervical spine injury. The injury left him quadriplegic. He has normal cognitive function and no problems with respiration. He is admitted to your service for treatment of pneumonia. The resident suggests antibiotics, chest physiotherapy, and hydration. One day while signing out Mr. H to the cross covering intern, the intern says "he should be a DNR, based on medical futility." Do you agree? Is his case medically futile, and if so, why?
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Mr. H is a 24-year-old man who resides in a skilled nursing facility, where he is undergoing rehabilitation from a cervical spine injury. The injury left him quadriplegic. He has normal cognitive function and no problems with respiration. He is admitted to your service for treatment of pneumonia. The resident suggests antibiotics, chest physiotherapy, and hydration. One day while signing out Mr. H to the cross covering intern, the intern says "he should be a DNR, based on medical futility." Do you agree? Is his case medically futile, and if so, why?
Medical futility means that an intervention, in this case CPR, offers no chance of meaningful medical benefit to the patient. Interventions can be considered futile if the probability of success (discharged alive from the hospital) is <1%, and/or if the CPR is successful, the quality of life is below the minimum acceptable to the patient.
In this case, Mr. H would have a somewhat lower than normal chance of survival from CPR, based on his quadriplegia (homebound lifestyle is a poor prognostic factor).
Furthermore, his quality of life, while not enviable, is not without value. Since he is fully awake and coherent, you could talk with Mr. H about his view of the quality of his life, particularly focusing on his goals and hopes for the future. You could share with him the likely scenarios should he have an arrest and the likely outcomes following CPR. After this discussion and clearly understanding Mr. H’s goals, you can partner with Mr. H to determine whether or not CPR is indicated in the event of an arrest.
In this case, CPR is not necessarily futile. A decision about resuscitation should occur only after talking with the patient about his situation, goals, and hopes in his life in order to make a shared and mutual decision.
Mrs. W is an 81-year-old woman with recurrent colon cancer with liver metastases admitted to the hospital for chemotherapy. Because of her poor prognosis, you approach her about a DNR order, but she requests to be "a full code." Can you write a DNR order anyway?
As a competent adult, this patient has the right to make decisions about her medical care. You must respect her wish not to be treated until she gives you permission to do so. However, it is especially important under these circumstances to clarify with Mrs. W her understanding of what CPR means and what her likely outcomes will be. To ensure that there is a clear understanding, addressing Mrs. W’s hopes and goals is essential. Perhaps she wants to live to see her granddaughter graduate from high school in two months, knowing that she will die soon thereafter, however she does not want heroic measures to prolong her life forever. Additionally, she may not want to live on machines for a prolonged period of time, and hence, if she survives cardiopulmonary arrest yet is dependent on a ventilator to breathe, her decision may change. Understanding Mrs. W’s goals may help you partner with her to make meaningful medical decisions that address her concerns and wishes throughout the duration of her illness.
After a goal oriented conversation, Mrs. W continues to request to be fully resuscitated in the setting of cardiopulmonary arrest. However, several days later, despite a worsening clinical condition, Mrs. W still requests to be a "full code." Your intern suggests that you sign her out as a "slow code." Should you do this?
“Slow codes” are deceitful, and therefore are not ethically justifiable. During slow codes, health care providers act in such a manner that provides families with the perception that they respect patients’ decisions yet they knowingly do not provide a full resuscitative effort. This approach has the potential to disrupt the patient-physician relationship. Rather than acting in a deceitful manner, ongoing conversations regarding Mrs. W’s goals while remaining transparent regarding the limitations of medicine is essential to develop a mutual and shared care plan between the medical providers and Mrs. W.