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Do-Not-Resuscitate Orders and Medical Futility
Michael D. Cantor, MD, JD;
Clarence H. Braddock III, MD, MPH;
Arthur R. Derse, MD, JD;
Denise Murray Edwards, RNCS, ARNP, MA, MEd, MTS;
Gerald L. Logue, MD;
William Nelson, PhD;
Angela M. Prudhomme, JD;
Robert A. Pearlman, MD, MPH;
James E. Reagan, PhD;
Ginger Schafer Wlody, RN, EdD, FCCM;
Ellen Fox, MD; for the Veterans Health Administration National Ethics Committee
Arch Intern Med. 2003;163:2689-2694.
This report addresses the difficult situation in which a patient or surrogate decision maker wishes cardiopulmonary resuscitation to be attempted even though the physician believes that resuscitation efforts would be futile. It also reviews current controversies surrounding the subject of do-not-resuscitate (DNR) orders and medical futility, discusses the complex medical, legal, and ethical considerations involved, and then offers recommendations as a guide to clinicians and ethics committees in resolving these difficult issues. Conflicts over DNR orders and medical futility should not be resolved through a policy that attempts to define futility in the abstract, but rather through a predefined and fair process that addresses specific cases and includes multiple safeguards. As it examines these issues, the report focuses on the Veterans Health Administration (VHA). Current national VHA policy constrains physicians from entering a DNR order over the objection of a patient or surrogate even if the physician believes cardiopulmonary resuscitation to be futile. The VHA National Ethics Committee recommends that VHA policy be changed to reflect the opinions expressed in this report. The National Ethics Committee, which is composed of VHA clinicians and leaders, as well as veterans advocates, creates reports that analyze ethical issues affecting the health and care of veterans treated in the VHA, the largest integrated health care system in the United States. This report does not change or modify VHA policy.
From the National Center for Ethics in Health Care of the Veterans Health Administration, Washington, DC (Drs Cantor and Fox), New York, NY (Dr Nelson), and Seattle, Wash (Dr Pearlman); the Department of Medicine, University of Washington School of Medicine, Seattle (Dr Braddock); the Center for the Study of Bioethics at the Medical College of Wisconsin, Milwaukee (Dr Derse); The Center for Health and Well-Being, West Des Moines, Iowa (Dr Edwards); the Department of Medicine, School of Medicine and Biomedical Sciences, State University of New York at Buffalo (Dr Logue); the Office of the General Counsel of the Department of Veterans Affairs, Washington, DC (Dr Prudhomme); and the Carl T. Hayden Veterans Affairs Medical Center, Phoenix, Ariz (Dr Wlody). Dr Reagan is in private practice in Enfield, NH. A complete list of the members of the Veterans Health Administration National Ethics Committee appears at the end of this article. The authors have no relevant financial interest in this article.
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