End-of-Life Issues

“Do Not Resuscitate” Order

Under review

In health establishments, there is generally a presumption in favor of life, so that when cardio-pulmonary arrest occurs, cardio-pulmonary resuscitation is performed, unless there are explicit orders to the contrary in the record. The presumption in favor of life seems to seek the patient’s best interests. But in fact, the requirement to write the order “do not resuscitate” in the patient’s record presupposes that the patient would consent to resuscitation. Also, if the patient clearly expresses his refusal to be resuscitated, the record must indicate it just as clearly.

An order not to resuscitate may also be suggested by the physician if the procedure is judged futile within the meaning given it by the American Heart Association, which sets out guidelines for justifying a physician’s unilateral decision not to resuscitate:

a) Resuscitation manoeuvres were tried but did not restore the circulation.
b) No physiological benefit may be expected from advanced resuscitation manoeuvres, considering that the patient’s vital functions are deteriorating despite the treatment.
c) No survivor has been reported in the studies in similar clinical situations.

The first two criteria indicate when resuscitation in progress should be stopped, whereas the third indicates when it should not begin.

Between these two extremes, (one where  the patient refuses CPR beforehand, and the other where the physician does not want  to begin it), there is a whole range of situations where communication is possible, allowing the patient and/or his family to explicitly discuss end-of-life issues with the physician. This is the course to choose, for, in addition to removing ambiguity, it enables one to give the patient the support and solace he wishes and requires.

Clinical Case 

A 78-year-old man, Mr. Pierre T., is suffering  from generalized arteriosclerotic vascular disease and arrives with pain in the right foot felt while at rest. The investigation reveals that his vascular condition is more than precarious. The patient suffers from end-stage renal disease and gangrene of the right foot. Metatarsal amputation and chronic hemodialysis follow.  

Mr. Pierre T. returns seven months later. The gangrene has reached the other foot, giving him severe pain while at rest. Mr. Pierre T. lets his wife speak for him, withdrawing when it becomes time to discuss treatment. His wife keeps repeating the same request: “The pain has to stop.”
What do you do?

Patients and their families do not always express themselves explicitly. This is especially true when death is at issue and highly charged emotions make discussion difficult for the patient, the family and the physician. Thus, it is up the physician to be vigilant and perceptive in this regard. In Mr. Pierre T.’s case, one might perceive his wife to be hinting at wanting to discuss the possibility of discontinuing the technical procedures and facing the inevitable.

In the context of advanced cancer, a certain institutional culture of palliative care has been developed. Yet there are many other clinical conditions for which the patient’s prognosis is equally poor, but for which no culture of palliative care has been developed. When we think of patients with terminal respiratory failure, or of patients like Mr. Pierre T. suffering from almost generalized arteriosclerotic cardiovascular disease, we realize that discussions on end-of-life issues should not be confined exclusively to oncologists. The physician should not lose sight of the clinical deterioration, even if it is marked by a  succession of remissions and exacerbations. The hopes raised by minimal, short-lived improvements should not unduly delay discussions about end-of-life issues and imminent death.

The example of Mr. Pierre T. is real. He had clearly adopted an attitude of withdrawal, entrusting his wife with the task of speaking on his behalf. Yet he showed no sign of incapacity to consent.

The question was raised with the treatment team: “What does Mr. Pierre T.’s wife mean when she asks that his pain stop?” The surgeon then returned to the bedside and calmly broached the subject with Mr. Pierre T. and his wife, offering to stop all surgical procedures but to provide relief and support to Mr. Pierre T. The latter then spoke. His choice was to stop treatment even before the hemodialysis began. With an amputated limb and an artificial kidney, he was a prisoner and no longer had any quality of life. Mr. Pierre T.’s wife then explained that, as his second wife, she feared the reaction of the children from his first marriage, if the palliative approach was chosen.  

The order not to resuscitate is one of many end-of-life issues. It may give rise to discussion on other issues, thereby improving the special professional relationship between physician and patient at this stage.

In all cases, it is never advisable for the physician to decide for the patient, based on what he or she thinks is best for him. In this sense, the criteria for non-resuscitation are merely tools to help in decision-making; but the decision cannot be made without the free and informed consent of the patient, his representative, or his close relatives. Even if the living will has no real legal value, it can be highly useful in this regard. However, the physician is not obliged to provide care he or she deems inappropriate. In the view of the Collège, the physician might more specifically indicate his or her refusal to take part in resuscitation he or she judges to be completely inappropriate, provided he or she makes certain that this difference of opinion will not interfere with the quality of follow-up care. Like any other treatment, resuscitation may be considered futile (that is, meaningless), if there is no hope of achieving the objectives expressed by the well-informed patient to his physician. These situations are not simple. Hence the importance of the physician reflecting on these questions beforehand.