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Ethics committee tackles issue of CPR
Hospital policies could be changed
The default policy of many hospitals is to have clinicians perform cardiopulmonary resuscitation (CPR) on dying patients except when there is a do-not-resuscitate (DNR) medical order signed by the patient.
This policy has continued even when the case is considered futile, when there is no true hope that the patient will be revived.
Now hospital ethics boards are taking a look at this policy, wondering if this should be changed.
The Harvard Community Ethics Committee in Boston, MA, spent months reviewing this issue, eventually writing a report and publishing a poster at the 2010 annual meeting of the American Society for Bioethics and Humanities (ASBH), held Oct. 21-24, 2010, in San Diego, CA, says Christine Mitchell, MTS, MS, associate director of clinical ethics in the department of global health and social medicine at Harvard Medical School in Boston, MA.
"A lot of places are revising their policies about the decision to not resuscitate, and they address those circumstances in which clinical consensus of CPR would not be beneficial for the patient," Mitchell says. "Some are saying, 'Just say no'; others are saying you need a process for overriding people who want to have CPR."
Harvard clinicians asked the community ethics committee to address the issue of DNR orders in the event of cases where physicians agree performing CPR would be the less humane route to take.
"When the person is going to die even with an intervention, CPR is not a nice way to go," Mitchell says. "It's putting a needle in the heart, pushing on the person's chest, using IVs and medications it's awful!"
The Harvard Community Ethics Committee, which is comprised of 16 diverse members of the public, began the discussion of futile CPR with some of the same assumptions that most people who do not work in health care might have, she notes.
"Community members came to this with the assumption that CPR is an effective treatment that should be done whenever anybody has a heart attack," Mitchell says.
After months of learning more about CPR and discussions with health care providers, committee members had a change of heart. One member wrote in the committee's report: "We learned that CPR is rarely effective, even when administered in a hospital setting, and we learned that it can sometimes be an incredibly intrusive and violent procedure not the gentle tap tap on the chest that our media exposure would have us believe," she adds.
CPR can prolong the dying process, and the committee addressed the terminology and ethics of unilateral DNR in a report about what the committee called "nontherapeutic CPR."
The committee thought the language of "unilateral DNR" was draconian and misunderstood, Mitchell says.
"'Medically futile CPR' was problematic and involved value judgments that went beyond just medical evidence, the report said," she adds. "The ethics committee thought those were not good ways of describing it; they thought it was clearer to say 'non-therapeutic' or 'non-beneficial CPR.'"
The problem with the word "futile" is that it can be used as a value judgment, as well as a medical judgment, Mitchell explains.
So the committee used the term "non-therapeutic CPR" to make the meaning clearer.
Once the report was complete, the committee sent it to ethics committees at Harvard-affiliated institutions.
"At the Harvard Children's Hospital we took this report into account when we revised our CPR policy," Mitchell says. "We put in a section on non-therapeutic CPR and listed procedures to follow for not doing CPR when it wouldn't benefit the patient, and we changed our language because of this report."
These procedures include having a clear consensus among physicians that CPR should not be done. This policy is communicated to patients and families, she adds.
The ethics committee's purpose is to think about these broader ethical questions and write reports with members' conclusions, Mitchell notes.
"We don't write policy," she says. "We give the lay public response from people who are not health professionals, but who are willing to take time to learn about an issue and let health care providers know how it strikes them."