ethics and medico legal aspects

5/16/2014 Ethics and Medico Legal Aspects of Not for Resuscitation

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3144433/ 1/5

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Indian J Palliat Care. 2010 May-Aug; 16(2): 6669.

doi: 10.4103/0973-1075.68404

PMCID: PMC3144433

Ethics and Medico Legal Aspects of Not for Resuscitation

Naveen Sulakshan Salins, Sachin Gopalakrishna Pai, MS Vidyasagar, and Manikkath Sobhana

Palliative Medicine Consultant, Palliative Medicine Unit, Departments of Radiotherapy and Oncology, Shiridi SaiBaba Cancer Hospital and Research

Centre, KMC Manipal, Manipal University 576104, India

Assistant Professor, Department of Medical Oncology, Shiridi SaiBaba Cancer Hospital and Research Centre, KMC Manipal, Manipal University

576104, India

Professor, Department of Radiotherapy and Oncology, Shiridi SaiBaba Cancer Hospital and Research Centre, KMC Manipal, Manipal University

576104, India

Medical Social Worker, Department of Radiotherapy, and Oncology, Shiridi SaiBaba Cancer Hospital and Research Centre, KMC Manipal, Manipal

University 576104, India

Address for correspondence: Dr. Naveen Sulakshan Salins; E-mail: [email protected]

Copyright Indian Journal of Palliative Care

This is an open-access article distributed under the terms of the Creative Commons Attribution License, w hich permits unrestricted use, distribution,

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Abstract

Not for resuscitation in India still remains an abstract concept with no clear guidelines or legal frame work.

Cardiopulmonary resuscitation is a complex medical intervention which is often used inappropriately in

hospitalized patients and usually guided by medical decision making rather than patient-directed choices.

Patient autonomy still remains a weak concept and relatives are expected to make this big decision in a short

time and at a time of great emotional distress. This article outlines concepts around ethics and medico legal

aspects of not for resuscitation, especially in Indian setting.

Keywords: Autonomy, Cardiopulmonary resuscitation, Ethics, Law

Life sustaining treatment is defined as any medical intervention, technology, procedure or medication that is

administered to a patient in order to forestall the moment of death, whether or not the treatment is intended

to affect the underlying life threatening disease or biological process. Decisions to withhold life-sustaining

treatment are made in two different situations. In the first, treatment is withheld from an actively dying

person whose existing condition indicates that effective cardiopulmonary resuscitation (CPR) is unlikely to be

successful or a successful CPR is likely to be followed by a length and quality of life that would not be in best

interests of patient to sustain. In the second, the decision is hypothetical, whereby the withholding of

treatment is made in advance, in a situation where a life threatening condition may eventuate.[1]

Cardiopulmonary resuscitation (CPR) came into widespread use in 1960s and soon it was apparent that it

was inappropriately used in some patients most obviously in advanced metastatic malignancy, end stage

organ failure and severe sepsis. CPR is a form of intensive and invasive treatment associated with high

mortality. Compared to other treatments, this intensive treatment is poorly discussed and documented.[2]

When a patient suffers sudden cardiopulmonary arrest usually, the decision whether or not to resuscitate

depends upon the physicians professional appraisal of the likelihood of successfully restoring

cardiopulmonary functioning of a particular patient versus the probable futility of a resuscitative attempt.

However, ethical, legal and sometimes financial implications must be taken into account. The issue of

resuscitation raises fundamental ethical questions about autonomy (patients wishes and choices),

beneficence (appropriate decision making), non -maleficence (harm avoidance) and justice (allocation of

limited resources). Medico legal aspects of CPR deal with issues such as competency of an individual in

decision-making, standards and processes of decision-making and dilemmas in instituting or withholding

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CPR in an incompetent individual.[3]

In the western world, more than 90% of patients reported to have information about CPR from television.

Patients often overestimated their likelihood of survival after CPR and this misinformation often led to

choosing resuscitation in situations in which successful outcomes were extremely unlikely.[4,5] A study of

popular medical dramas projected an unusually high survival rate following a CPR in contrary to the actual

figures.[6] Often patients and patients relatives participate in decisions about resuscitation and end of life at

a time of great emotional distress. In a short period of time, they are expected to digest and evaluate complex

medical information and make decisions about themselves or for the loved ones. Therefore, prior knowledge,

information and media portrayal strongly influence the decision making.[7] A study reported that 50% of

elderly patients, who first chose to be resuscitated, changed their opinion after they received more detailed

information about the CPR process and possibility of surviving.[5] Educational intervention consisting of

handouts and a videotape about advance directives improved knowledge and intended to change attitudes

and behavior about resuscitation.[8] It is important for the physicians to explain the process, clinical

accompaniments and aftermath including intubation, mechanical ventilation, artificial feeding, hydration,

supplemental oxygen and pharmacological agents. Therefore, decision of instituting CPR is not a single

ethical decision but a number of choices either bundled together or spread over a period of time.[9]

In the past, issuing a not for resuscitation order was considered as a part of doctors therapeutic prerogative

and was often not formally registered. This practice still exists in many places and countries. The main ethical

problems with such informal practices are that they exclude patients and relatives from the process of

decision-making process and give paternalistic doctors absolute power over the patient.[10] A Hungarian

study showed that medical practice in that country is rather paternalistic and the most important factor

influencing the decision of not for resuscitation was the opinion of the doctor in charge.[11] Indian medical

practice works on similar lines. Resuscitation status should not be just based on medical grounds and value

input from patients and families should always be considered. Successful outcomes of resuscitation mean

restoration of patients health to their pre-arrest state. Hence, resuscitation must be instituted in only those

patients where there is a reasonable chance of restoring cardiopulmonary functions, optimal mental capacity

and length and quality of life that would be in the best interests of patients to sustain.[12] CPR is considered

futile if its purpose cannot achieve reasonable length and quality of life and qualitative definition of futility

must include low chance of survival and low quality of life afterward. The framework for decisions about

futility can be best achieved by accurate prognostication, good communication, respecting patient choices,

value opinion of other healthcare providers, local society factors, and cultural and social consensus.[13] In

2005, The Royal College of Anesthetics, Physicians, Intensive Care Society and Resuscitation Council (UK)

published new resuscitation standards. The recommendations made it mandatory: (a) to identify patients in

whom cardiopulmonary arrest is an anticipated terminal event and institution of CPR is inappropriate (b) for

all institutions should ensure that there is a clear and explicit resuscitation plan for all patients (c) when there

is no resuscitation plans and wishes of the patient are unknown, the resuscitation decision should be made by

the attending medical emergency team in the best interests of the patient.[14]

Patient autonomy should be cornerstone in deciding about patients resuscitation status. Accurate

information about the condition, prognosis, and nature of the proposed intervention, alternatives, risks and

benefits may enable the patients to make better decisions about resuscitation and end of life. Physicians

seldom discuss advance directives even with their seriously ill patients.[15] Advance directives are the term

applied to any expression of a persons thoughts, wishes, or preferences for his or her end of life care. It

usually specifies nature and extent of care and it could be based on conversations, written directives, and

living will or through medical power of attorney. In a living will, the patient gives directions to physicians

about provision of medical care should the patient become terminally ill and unable to make decisions.

Competent patients in anticipation of future incompetence could appoint a family member or friend as a

surrogate decision maker and grant durable power of attorney that allows them to take medical decisions for

the patient if he or she loses the capacity to make their decisions. Surrogate decision makers should always

base their decisions on patients previously expressed wishes. Physicians can always override the decisions of

the surrogate decision makers if these decisions are not made in the best interests of the patient. It is

important to explore the opinions of surrogate decision makers and provide them knowledge and information

to make the best possible decision. If there are non-negotiable difference of opinion between doctors and

surrogate decision makers regarding appropriateness of resuscitation, then it should be further explored and



should always be referred to the hospital ethics committee.[16,17] Decision making by doctors regarding

resuscitation and end of life care depends upon patient-dependent factors and personal characteristics of

doctor. Doctors should be open to discuss end of life preferences openly with other health care providers and

surrogate decision makers. Junior doctors in training would benefit from the supervision of the experienced

colleagues in dealing with process of end of life care and not for resuscitation.[18,19]

The first hospital policies on not for resuscitation were published in medical literature in 1976. Results from

the MERIT study showed that in UK 22% of patients attended by a medical emergency team (MET) team are

issued not for resuscitation order at the time or after a MET call and in Australia 23% of all MET calls were

appropriate for not for resuscitation order and 3.8% of the patients were issued not for resuscitation order

during the time of medical emergency team attendance.[20] Dutch hospital study showed medical staff were

poorly documenting not for resuscitation orders. The possible barriers for limited documentation were: (a)

inability to discuss resuscitation decisions (b) lack of knowledge about the facts and consequences of

resuscitation and (c) unwillingness to make resuscitation open for discussion.[21]

An American hospital study identified similar barriers for not documenting not for resuscitation and in

addition other barriers were: (d) not expecting the patient to die during admission (e) waiting for the patients

own doctor (f) not having enough knowledge about a particular patient (g) not finding the right moment or

spot to discuss it and (h) just forgetting about it.[22]

In India there is no formal process of discussion and documentation of not for resuscitation. Patient

autonomy still remains a weak concept and surrogate decision making by the next of kin or the financial

provider usually overrides patient wishes.[23] Up to 80% of the health care bills are paid by the patients and

less than 20% depend on the public health care, which is severely crippled with acute bed shortages and lack

of infrastructure. Socio-economic considerations complicate patient autonomy, issues around resuscitation

and delivery of end of life care.[24] The Indian Society of Critical Care Medicine in 2005 proposed guidelines

for limiting life-prolonging interventions and providing palliative care at end of life. The doctors are morally

and ethically obliged to provide good prognostication and initiate discussions around treatment options,

benefits of life prolonging treatment, and resuscitation. Patients and relatives should be well informed about

realistic outcomes of a disease modifying treatment, withholding and withdrawing treatment.[25] In 2002,

122 Indian physicians participated in a study that evaluated physicians beliefs regarding end of life care.

Majority of physicians did not apply not for resuscitation order and in most of the cases applied these were

primarily discussed with the family. In 2008, AIIMS study, 40 Indian pediatricians participated in end of life

survey and the 3 major factors influencing withholding support in a critically ill child was a) childs likelihood

of survival b) potential for neurologically intact survival and c) quality of life. The results of Indian

pediatricians end of life practice survey showed that 45% of pediatricians initiated not for resuscitation

orders in a dying child. 55% of them withheld active treatment and none had withdrawn active treatment.

Prognosis and limiting life prolonging measures were discussed with the families. Other clinical units and

supervisors were consulted during discussion about ethics of not for resuscitation. The study of deaths in

Indian ICU setting showed only 22% had life limiting management when compared to 74% in the western

setting. Among the 298 deaths only 4 had Not for resuscitation orders.

Left against medical advice (LAMA) is a common situation seen in Indian setting where family unilaterally

withdraws treatment due to financial constraints.

Indian Society of Critical Care Medicine in 2005 put forth a position paper outlining guidelines for not for

resuscitation in an Indian setting. The recommendations were a) Duty of the physician to discuss with

honest and clarity regarding prognosis and treatment options b) When the fully informed capable patient or

family desires to consider palliative care, the physician should offer the available modalities of limiting life-

prolonging interventions c) Physician must discuss the implications of forgoing aggressive interventions

through formal conferences with the capable patient or family, and work toward a shared decision-making

process d) If there is a conflict then pending consensus all active treatment should continue e) Responsibility,

initiation and implementation of decision of not for resuscitation rests with the treating physician f) Clear

documentation of the decision, directives and end of life wishes h) Withdrawal of life support should be

consistent with good practice, ethically right and within the limits of existing law i) Physician is obliged to

provide compassionate and effective palliative care to the patient and family. The absence of guidelines for

withdrawal and withholding of life support in Indian law is perceived to be the most important obstacle for

providing good end of life care. The study found that the barriers for providing good end of life care were



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primarily legal, administrative and lack of hospital policies and were not due to ethical and cultural barriers.

[26] Indian legal system maintains an ambiguous stance towards issues relating to limiting life support,

withholding and withdrawing treatment and resuscitation. The Supreme Court of India in 1994 ruled that

an attempt to hasten death in terminal illness might be viewed as a natural process. A person cannot be

forced to enjoy the right of life to his detriment, disadvantage or dislike.[27] The above judgment of the

Supreme court was overruled by the Constitution bench which ruled that permitting termination of life in the

dying or vegetative state is not compatible with Article 21 of the Constitution which states that No person

shall be deprived of his life or personal liberty except according to procedure established by law.[27] The

interpretation of Gian Kaur case disallows the concept of Euthanasia as it violates Article 21 of the Indian

Constitution. As withholding and withdrawing life support amounts to abetment of suicide and abetment of

suicide is a punishable offence according to Indian Penal Code. These issues are addressed by the Law

commission of India and until such laws come into effect patient autonomy, family wishes and medical

decision making at end of life will still remain guided by the Indian Penal Code.[24]

Footnotes

Source of Support: Nil

Conflict of Interest: None declared.

REFERENCES

1. Melltorp G, Nilstun T. Decisions to forego life-sustaining treatment and the duty of documentation.

Intensive Care Med. 1996;22:10159. [PubMed]

2. Hayes S, Stewart K. The role of audit in making do not resuscitate decisions. J Eval Clin Pract. 1998;5:305

12. [PubMed]

3. Kapp MB. Legal and ethical aspects of resuscitation: An annotated bibiliography of recent literature.

Resuscitation. 1987;15:28997. [PubMed]

4. Schonwetter RS, Walker RM, Kramer DR, Robinson BE. Resuscitation decision making in the elderly: The

value of outcome data. J Gen Intern Med. 1993;8:295300. [PubMed]

5. Murphy DJ, Burrows D, Santilli S. The influence of the probablity of survival on patients preferences

regarding cardiopulmonary resuscitation. N Engl J Med. 1994;330:5459. [PubMed]

6. Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on television: Miracles and

misinformation. N Engl J Med. 1996;334:157882. [PubMed]

7. Turow J. Televison, story telling and medical power. New York: Oxford University Press; 1989.

8. Yamada R, Galecki AT, Goold SD, Hogikyan RV. A multimedia intervention on cardiopulmonary

resuscitation and advanced directives. J Gen Intern Med. 1999;14:55963. [PMC free article] [PubMed]

9. Petty T. Resuscitation decisions. Clin Geriatr Med. 1986;2:53545. [PubMed]

10. Tomlinson T, Brody H. Ethics and communications in do-not-resuscitate orders. N Engl J Med.

1986;318:436. [PubMed]

11. Elo G, Dioszeghy C, Dobos M, Andorka M. Ethical considerations behind the limitation of

cardioplumonary resuscitation in Hungary-the role of education and training. Resuscitation. 2005;64:717.

[PubMed]

12. Holm S, Jorgensen EO. Ethical issues in cardiopulmonary resuscitation. Resuscitation. 2001;50:1359.

[PubMed]

13. Callahan D. Medical futility, medical necessity. The-problem-without-a-name. Hastings Cent Rep.

1991;21:305. [PubMed]

14. Gabbott D, Smith G, Mitchell S, Colquhoun M, Nolan J, Soar J, et al. Cardiopulmonary resuscitation

standards for clinical practice and training in the UK. Resuscitation. 2005;64:139. [PubMed]

15. Part 2: Ethical aspects of CPR and ECC. European Resuscitation Council. Resuscitation. 2000;46:1727.



[PubMed]

16. Hines S, Glover J, Holley J, Babrow A, Badzek L, Moss A. Dialysis patient preferences for family based

advance care planning. Ann Intern Med. 2000;133:8258. [PubMed]

17. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses

and preferences for outcomes and risks of treatments (SUPPORT).The SUPPORT Principal Investigators.

JAMA. 1995;274:15918. [PubMed]

18. Hinkka H, Kosunen E, Metsanoja R, Lammi UK, Kellokumpu-Lehtinen P. To resuscitate or not: A

dilemma in terminal care. Resuscitation. 2001;49:28997. [PubMed]

19. Elshove-Bolk J, Guttormsen AB, Austlid I. In-hospital resuscitation of the elderly: Characterstics and

outcome. Resuscitation. 2007;74:3726. [PubMed]

20. Chen J, Flabouris A, Bellomo R, Hillman K, Finfer S. The medical emergency team system and not-for-

resuscitation orders: Results from the MERIT study. Resuscitation. 2008;79:3917. [PubMed]

21. Meilink M, van de Wetering K, Klip H. Discussing and documenting (do not attempt) resuscitation orders

in a Dutch Hospital: A disappointing reality. Resuscitation. 2006;71:3226. [PubMed]

22. Eliasson AH, Parker JM, Shorr AF, Babb KA, Harris R, Aaronson BA, et al. Impediments to writing do-

not-resuscitate orders. Arch Intern Med. 1999;159:22138. [PubMed]

23. Adhikary SD, Raviraj R. Do not resuscitate orders. Indian J Med Ethics. 2006;3:1001. [PubMed]

24. Kamat V. Guiding light at the end of the tunnel. Indian J Med Ethics. 2006;3:1034. [PubMed]

25. Mani R, Amin P, Chawla R, Divatia J, Kapadia F, Khilnani P. Limiting life-prolonging interventions and

providing palliative care towards the end of life in Indian intensive care units. Indian J Crit Care Med.

2005;9:96107.

26. Barnett VT, Aurora VK. Physicians beliefs and practice regarding end-of-life care in India. Indian J Crit

Care Med. 2009;12:10915. [PMC free article] [PubMed]

27. Rao MJ. Legal issues related to the limitation of life support: A review of the international legal process.

Indian J Crit Care Med. 2005;9:1159.

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