Human Exceptionalism

Futile Care Theory on the March: Imposed Do Not Resuscitate Orders

One of the most momentous decisions in medicine is the “do not resuscitate” order, or DNR. This doesn’t mean no treatment, nor does it mean no life-sustaining treatment. It means that if a patient suffers cardiac arrest, no CPR will be administered.

Because DNR’s basically mean that medical personnel will not prevent imminent death, it has always been the patient/family/surrogate that has had the exclusive power to authorize the placing of a DNR on the chart.

This may soon change in Veteran’s hospitals. A long article in the Archives of Internal Medicine by members of the Veterans Health Administration National Ethics Committee advocates giving power to hospital ethics committees to place a DNR on patient charts over the objections of the rightful decision makers about such matters. (Hit this link to see the Abstract)

Yes, yes, the claim is that it should be reserved for “exceptional” circumstances and that there will be many procedural steps to be taken before the ethics committee can vote a patient out of the life boat. But it should also be noted that one of the reasons given for the policy is resource management, and what could turn into an invidious form of discrimination based on state of health or ability:

Autonomy may also conflict with responsible stewardship of finite resources..Futile care provided to one patient inevitably diverts stall time and other resources away from other patients who would likely benefit more. This is especially the case for VHA, which operates within a fixed budget of appropriated funds.

I believe there are times when CPR is medically inappropriate, that is, when the patient is so far gone that there is virtually no chance of saving life, and great chance of doing harm in the process (broken ribs, etc.). If such cases occur, the proper place for the decision is in the light of day, not behind closed doors. Courts can be asked for permission to place the DNR on the chart, with proper independent investigations given, and the public defender or other paid for counsel for family who object.

Letting ethics committee members make these decisions without a public record, the right to cross examination, and appeals–especially in light of the recent scandals in the VA about quality of care–is no way to inspire confidence. Futile Care Theory should not be imposed upon our veterans after all they gave to their country.

Post Script: I just noticed that the article is a few years old. This doesn’t mean it is irrelevant, however, because it shows where the bioethics movement wants to take us.

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