Patients and their families expect doctors to pull out all the stops to prolong life.  Now, a growing number of physicians want the right to order a 'Do Not Resuscitate' or DNR on patients.  It's part of a trend by doctors to deny treatments they consider medically futile.

 

Medical futility is described as proposed therapy that should not be performed because available data have shown that it will not improve the patient's medical condition.  It refers to the belief that in cases where there is no hope for improvement of an incapacitating condition, that no course of treatment is called for.   Some experts say it's based on the Greek legend of trying to bail a well with a sieve.  Doing that doesn't work no matter how hard you try. 

 

Why would doctors try to impose their will not to perform cardiopulmonary resuscitation or CPR?  Each case has unique circumstances.  Here's one that's been in the news lately.  Last August, a 46-year old cancer patient named Man Kee Li was admitted to a hospital in Toronto.  He told his doctors he wanted CPR if his heart stopped.  His doctors initially agreed.  But in October, the doctors and the hospital imposed a DNR order - meaning no CPR.  The family obtained a court order revoking the DNR. Ultimately, the family withdrew their legal challenge because the man's condition was grave. In this case, from media reports, it appears that the doctors who imposed a DNR order because they believed CPR was highly unlikely to save his life.  In a written statement, an executive with the said "When clinical teams determine that further interventions would have no benefit to the patient . . . ethically and legally, health-care providers are not obliged to provide interventions that lie outside the standard of care and would be of no benefit, and indeed may well cause harm to a patient." 

 

Here's the thing that makes the whole concept of medical futility controversial.  Doctors do not always know when treatment is futile.  To know for sure, you need research data showing the patient's outcome is dismal when you do the treatment.  In many cases, doctors don't have that kind of research data.  There's no consensus as to the statistical threshold for a treatment to be considered futile.  In the absence of data, some physicians declare a treatment futile without knowing if it is or isn't.  They trust their gut, and that can be disconcerting if you're a family member dealing with a loved one who is dying. 

 

That said, doctors who refuse to do CPR believe they're acting within ethical grounds.  Besides medical futility, doctors and hospitals invoke the Hipocratic Oath to do no harm.  In the case of CPR, it may be physical harm in the form of cracked ribs or harming the dignity of the patient.  Combine medical futility with harm, and you have some powerful arguments for refusing CPR.  The other ethical argument has to do with the power relationship between doctors and their patients.  Right now, your doctor recommends treatment and you or your surrogate consents.  Under that system, the only way you get - say, an angioplasty or gall bladder surgery - is if your MD agrees to do it.  You want a new car?  Go to a showroom and demand one in the color you choose.  Want a bypass?  Try seeing your doctor and demanding it.  In that system, you can't demand CPR if your doctor doesn't want to do it.  Of course, you sue them for failing to do so.   There's another ethical argument that's starting to gain some traction here.  Some bioethicists say that patients and their family may have a responsibility or even a duty to refuse futile treatments that delay an imminent death.

 

Given these issues, what should patients do?  The best time to think about end-of-life issues is when you are sound mind and body.  I suggest you draft some advance directives.  Use clear language.  Don't say " no heroic measures".  Instead, be specific about situations in which you do or don't want CPR, a ventilator, etc.  Advance directives are always a work in progress; be prepared to change them as circumstances dictate.  If you prepare advance directives, you need to appoint a power of attorney to make decisions on your behalf.  Choose someone who lives close by rather than across the country.  Ideally, that person should be able and willing to make decisions based on the patient's values and not theirs'.

 

One more thing.  Good communication with your family and with your health care providers is the key.  Fortunately, disputes between health professionals and patients is quite rare.  When they happen, it's usually because of poor communication.