New Report on DNR: Time to Intervene?

The UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD) has released a new report that highlights the process of care for adult patients who received cardiopulmonary resuscitation in an in-hospital setting.  


The report takes a critical look at areas where the care of patients might have been improved, and factors which may have affected the decision to initiate a resuscitation attempt. Notably, the report found that even when a DNACPR decision had been made it was not always followed, and 52 patients underwent CPR despite their explicit DNACPR decision.


NCEPOD Chairman Bertie Leigh said that he hoped this report would prompt a rethink on the limits of what is possible, and act as a wake up call to the NHS: “In nearly half of all the cases we reviewed there was a failure to formulate an appropriate care plan on admission, and a failure, often over several days, to find out what the patient’s wishes were – and to carry them out.”  “We are at a crossroads. All of us need to recognise and accept the limits of what can be achieved in medicine to the benefit of the patient, and a ‘ceiling of treatment’ described and agreed with the patient wherever possible. Doctors should only administer CPR where a patient has consented, or if the doctor is satisfied it is in the patient’s best interests.”

Death by ICU: End-of-Life Care in America

MedSmart has released a new free report, Death-by-ICU: End-of-Life Care in America.


MedSmart generally advocates for greater caution in assessing your medical interventions generally. The reason is that our medical interventions – not just invasive procedures, but medications as well – can often cause more harm than benefit.  Many consumers have too much fear of death and disease and too little fear of the injury possible with medical interventions that may hasten their death with treatment-induced disease.  And if aggressive medical interventions pose a greater-than-appreciated risk for the average patient, don’t you think the risk is even greater for vulnerable patients at death’s door?

• Patients with end-stage disease will likely live longer without having their frail and vulnerable bodies subjected to the invasive trauma of fruitless surgeries and interventional procedures that very likely cause more harm than good;
• Studies indicate that when dying patients were shown videos of what their final days would be like in a hospital intensive care unit (ICU) they chose to reject ICU care – unanimously;
• ICU physicians have described their dying patients kept “alive” on ventilators as “broken survivors” existing in a state of suspended animation; and
• Billions of dollars we can no longer afford are wasted on futile medical interventions on frail patients with end-stage disease.

This list of bullet points above is a pretty powerful cumulative argument for reconsidering our assumptions and our approach to end-of-life care.  Because we appear to have been wrong all along about what’s actually best for our loved ones confronting death – and what they’d actually want if they knew how intensive treatments would adversely affect their quality of life in their final days and hours of life.  We don't want the guilt of thinking we did anything less than we could have for parents and other loved ones who may have done so much for us. There’s nothing more normal or understandable.  But that does not make it right – not if we’re wrong in our assumptions and end up making their final memories of life filled with unnecessary pain and suffering.


Prior generations did not have as many technological options for artificially prolonging the dying process. And as these patients themselves seem to recognize better than the rest of us, prolonging the dying process is not necessarily the same as extending the living process.  Indeed, the report cites a study where the patients who rejected so-called “heroic” intensive medical measures in favor of comfort-focused palliative care lived about 33% longer – and were over 50% less depressed about dying – than those who chose death-by-ICU.


MedSmart's Report suggests that maybe all our angst about dying, for all its good intentions, is simply wrong-headed – and counter-productive for those we’re concerned about.  If what we’re doing with all this aggressive late-stage treatment is not extending our loved one’s lives – and may even hasten their demise – then maybe we need to rethink our attitudes and choices about this most delicate of decisions.

What should medicine do when it can't save your life?

The modern healthcare system has become proficient at staving off death with aggressive interventions.  And yet, eventually everyone dies--and although most Americans say they would prefer to die peacefully at home, more than half of all deaths take place in hospitals or health care facilities. 


A new book, At the End of Life: True Stories About How We Die, tackles this conundrum head on.  These twenty-two compelling personal-medical narratives explore death, dying and palliative care, and reveal the inner workings of a system in which doctors, patients and their loved ones battle to hang on--and to let go. 

Video of Rasouli Hearing

The video of the hearing on Hassan Rasouli's motion to quash the appeal is now available here on the Supreme Court's website.  The Court denied the motion, permitting the appeal to proceed.

Finally - Measuring Use of Texas Futility Law

The Texas Hospital Association has launched a survey to measure use of the TADA dispute resolution process.  Hopefully, this will provide some much-needed light to the frequency and manner in which this is used.

Combining Scholarship and Service

I am in San Francisco, this week, for the American Thoracic Society International Conference.  This is the third year in which I was invited to present at this conference.  And it is always a thrill and an honor.  After all, I research and write a great deal about the law concerning end-of-life medicine.  ATS is the main conference for critical care physicians, those most frequently and directly affected by end-of-life law.  So, this is a great opportunity to hear from them in-person.

But I am fortunate to be involved, here, in something even more exciting.  This is the second year in which I have been a member of two drafting committees.  One is writing a policy on when clinicians can exercise a conscience-based objection to providing a healthcare service.  The other committee is writing a policy on the prevention and resolution of medical futility disputes.  While these policies will ultimately be published in medical journals, they have a special status.  As official medical society recommendations, they will materially shape and guide practice. 

It is rewarding to know that one’s efforts will have a real practical impact.  I was thrilled to have the New Jersey Appellate Division cite my work in a published opinion in 2010.  But I did not know that would happen when I wrote the article in 2007.  In contrast, I already know that these ATS projects are destined to be popular and authoritative.     

Defending the Slow Code

At the end of 2011, Lantos and Meadow published “Should the ‘Slow Code’ Be Resuscitated?” in AJOB.  (Lantos also discusses the article in this Bioethics Channel podcast.)  I applaud Lantos and Meadow for defending the slow code (or at least the short code).  As John Stuart Mill said in defending freedom of expression:

1. First, if any opinion is compelled to silence, that opinion may, for aught we can certainly know, be true. To deny this is to assume our own infallibility.             
2. Secondly, though the silenced opinion be an error, it may, and very commonly does, contain a portion of truth; and since the general or prevailing opinion on any subject is rarely or never the whole truth, it is only by the collision of adverse opinions that the remainder of the truth has any chance of being supplied
3. Thirdly, even if the received opinion be not only true, but the whole truth; unless it is suffered to be, and actually is, vigorously and earnestly contested, it will, by most of those who receive it, be held in the manner of a prejudice, with little comprehension or feeling of its rational grounds.
4.  Fourthly, the meaning of the doctrine itself will be in danger of being lost, or enfeebled, and deprived of its vital effect on the character and conduct: the dogma becoming a mere formal profession, inefficacious for good, but cumbering the ground, and preventing the growth of any real and heartfelt conviction, from reason or personal experience. 

Still, I cannot agree with Lantos & Meadow’s core thesis.  I just stomach the lack of transparency.   And I am too aware that even well-meaning subterfuge is the too-common breeding ground for the operation of bias and prejudice.  In short, the risks are too high. 

But there is something else in the same Lantos and Meadow article that I really like:  a summary of the three approaches to futility disputes:

•          Conversational – try to convince the surrogate
•          Deferential – accede to the surrogate’s wishes
•          Confrontational – refuse and override the surrogate

The conversational approach is always appropriate and should always be undertaken first.  If, in the rare instance in which a conversational approach is not successful, a deferential approach might sometimes be appropriate.  A common example is the classic short-term accommodation until the out-of-town relative can arrive at the hospital to say “goodbye.”  Other times, a confrontational approach is most appropriate.  Too often, however, providers take a deferential approach, when a confrontational approach would be most appropriate.