medical futility dnr

Medical Futility &

Resuscitation (DNR)

28-12-2011 Sree/Futility&DNR 1 Dr.Sree

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Dr. Sreedharan V. Koliyadan. MS; DNB; FRCS Consultant; Department of Surgery Sultan Qaboos University [email protected]

First I will define what I conceive medicine to be. In general terms, it is to do away with

the sufferings of the sick, to lessen the violence of their diseases, and to refuse to treat those who are overmastered by their

disease, realizing that in such cases medicine is powerless.

— The Hippocratic Corpus


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Medical Futility & Do-Not-Resuscitate Medical Futility: Definition Types Purposes Limitations Estimation Process Do-Not-Resuscitate Orders: Definition Purpose Limitations Process Policies: RH/SQUH DNR: Islamic perspectives :


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Futility Definition: Futile (adj): incapable of producing any useful result; pointless (Oxford dictionary)

Futility (noun): pointlessness or uselessness: Medical Futility: a judgment that further medical treatment of a patient would have no useful result. Origin: Futili (Latin) from Greek


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Futility is uselessness�The questions now is uselessness on whos view?�1. Physician�2. Patient or SDM�3. Society�� Futility means uselessness or lack of intended result. Medical futility means Danaus, the King of Argos had 50 daughters, all of them he was obliged to be married to the 50 sons of his half brother Aegypteus. Danaus asked her daughters to kill their husbands in the first night, that all except one obliged. Later these daughters were condemned to an afterlife where they tried to collect water in a pots with sieve at the bottom, that never fill up; the pot was called Futil and the act futili.

Futility: Types Quantitative: likelihood of survival Qualitative: likelihood of quality of life after survival

Trotter G. Editorial Introduction : Futility in the 21 st Century. HEC Forum. 2007;19:1–12.

Chwang E. Futility clarified. The Journal of law, medicine & ethics : a journal of the American Society of Law, Medicine & Ethics [Internet]. 2009 Jan;37(3):487–95, 396


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Quantitative futility:after the intervention, the likelihood of benefit is exceedingly small�Qualitative Futility: After the intervention, there will be a likelihood of preserving biological life but not a person CPR for a persistent vegitative patient when restores the cardiac rhythm is quantitatively or physiologically is not futile but qualitatively futile.

1. Physiological 2. Imminent demise 3. Lethal condition 4. Qualitative

Futility: Types

Slosar JP. Medical Futility in the Post-Modern Context. HEC Forum. 2007;19(1):67–82.


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The futility are of four types accoring to Brody and Harvey 1995:�1. Physiological futility: the physiological goal achieved (cardiac rhythm restored)�2. Imminent demise futility: Physiologic goal achieved but duration of survival very short�3. Lethal condition futility: Patient survive for some time but die after few days or weeks but not years�4. Qualitative futility: patient survives but with poor quality of life

Futility: Purpose

Baily MA. Futility, Autonomy, and Cost in End-of-Life Care. Journal of Law , Medicine and Ethics. 1989;00:172–82.

Decide Interventions Reasons for the concept of medical futility: 1. Absence of beneficence 2. Creation of harm 3. Respect for autonomy of patient/ surrogate 4. Distributive justice 5. Autonomy of physician

Joseph R. Hospital policy on medical futility - does it help in conflict resolution and ensuring good end-of-life care? Annals of the Academy of Medicine, Singapore [Internet]. 2011 Jan;40(1):19–7.


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Reasons for the concept of medical futility:�1. Abscence of beneficence by interventions�2. Creation of harm�3. Respect for autonomy of patient/ surrogate�4. Autonomy of physician not to compell to administer interventions that he believed is futile�5. Distributive justice: direct limited resources to beneficial purposes 2. Futility can potentially be used to practice paternalism (implementing decisions based on physicians values on the premise of futility) that will under override patient autonomy.�Physicians personal autonomy (the fundamental right of "not to do against my personal values") cannot be used in clinical decision making situations like DNR, but it is a ground to refuse to participate in abortion and euthanasia.�Physician have duty to respect patient autonomy but at the same time have duty to the society at large who pay for the treatment.In this respect, physicians are not obliged to offer futile treatments to patients when cost is a consideration and that cost is not paid by the individaul patient alone but come from government or tax payers or insurance

Futility: Estimation


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Recovery of consciousness, particularly recovery with good function, is highly unlikely after 3 months in a PVS associated with a nontraumatic cause or after 12 months for cases involving trauma. Because the functions regulated by the hypothalamus and brain stem (spontaneous respira- tion, cardiovascular control and the gag reflex) are often preserved, the life ex- pectancy of patients in a PVS is substantial, 2 to 5 years on average.�The joint statement further notes that “[t]here is no obligation to offer a person futile or nonbeneficial treatment.”1(Canadian medical Assosciation)�Patients in persistent vegitative state are incapable of conscious experiences including pain and sufferings, this is supported by the Positron Emission tomographic studies.�Implementing or decision to implement DNR on a patient in persistent vegitative state on the ground of medical futility against the wishes of surrogate often lead to legal interventions and so far such legal verdicts often were in favour of the surrogates especially if the surrogated demand CPR on the gound of religious or cultural believes

Futility: Estimation : 1. The AHA Guidelines for CPR and Emergency Cardiac Care: "no survivors after CPR have been reported under the circumstances in well-designed studies." 2. Schneiderman(1990): Intervention is futile if it has failed the last 100 times it has been attempted 3. The American Thoracic Society " intervention futile if it is highly unlikely to result in meaningful survival" [Editorial]. W hen Is CPR Futile ? Journal Of The American Medical Association. 1995;273(2):156–8.


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The futility is defined variously by different authors:�1. The Amercian Heart Assosciation Guidelines for CPR and Emergency Cardiac Care: '"no survivors after CPR have been reported under the circumstances in well-designed studies."�2. Schneiderman(0000): Intervention is futile if it has failed the last 100 times it has been attempted�3. The American Thoracic Society " intervention futile if it is highly unlikely to result in meaningful survival"��American Heart Association Guidelines allow unilateral DNAR orders when no survivors after CPR have been reported��Choosing a survival threshold of 0.5% suggested to define futility wihout compelling arguement to favour this magic number

Futility: Estimation Overall survival to home after CPR: 18% Futility: Quantitative criteria: <1/100 < 13% Survival <5% survival Futility: Individual diseases: Hypotension: survival 2% Renal failure: 3% AIDS: 2% >70yrs: 4% Other Scales: APACHE II ASA

Ehlenbach WJ, Barnato AE, Curtis JR, Kreuter W, Koepsell TD, Deyo R a, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. The New England journal of medicine [Internet]. 2009 Jul 2;361(1):22–31.

Lawson a. Futility. Current Anaesthesia & Critical Care [Internet]. 2004 Aug [cited 2011 Dec 23];15(3):219–23.


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1. The proportion of in-hospital deaths preceded by CPR increased, whereas the proportion of survivors discharged home after undergoing CPR decreased. Black race was associated with higher rates of CPR but lower rates of survival after CPR. 2. An intervention is considered futile if that intervention did not work for 100 previous cases or 13% probability of survival, or 5% proability of survival arbitrarily by various authors.

Futility: Limitations

Futility of Physician vs. Futility of patient/SDM Estimation of Quantitative Futility Estimation of Qualitative Futility (Values)

Luce J. Physicians do not have a responsibility to provide futile or unreasonable care if a patient or family insists. Critical Care. 1995;23(4):760–6. 28-12-2011 Sree/Futility&DNR 11 Dr.S

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Schneiderman et al. suggest that any treatment that was not effective in the first 100 patients in the physicans experience or in published reports, or treatments that are not beneficial to improve the person a s awhole (in contrast to effective where only a part of body may improve) is futile treatment.�Other methods to qualtify futility are the critical care scroing systems like ASA and Acute Physiology and Chronic Health Evaluation (APACHE) system that predicts mortaility of a given patient with positive predictive value 80% and negative predicitve value 90%�Concept of futility on medical grouns taken by a physican may not be a futility for patient or SDM as patient or SDM define it based on the values and goals rather than the outcomes defined by physicians.�Lantos :"When the chance of success is low, but the alternative to treatment is death, and the patient desires therapy, the presumption should be in favor of treatment.''

“Physicians are NOT obliged to provide care when there is scientific and social consensus that the treatment is ineffective.”

American Heart Association

“Physicians are under no ethical obligation to render treatments that they judge have no realistic likelihood of medical benefit to the patient”

American College of Emergency Physician, 1998

CPR maybe withheld even if requested by the patients “when efforts to resuscitate a patient are judged by the treating physician to be futile”

AMA Council on Ethical and Judicial Affairs, 1991

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Unilateral vs Bilateral Decisions

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…“futility is a professional judgment that takes precedence over patient autonomy and permits physicians to withhold or withdraw care deemed to be inappropriate without subjecting such a decision to patient approval.” Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: its meaning and ethical implications. Ann Intern Med. 1990 Jun 15;112(12):949-54.

“Whereas patients have a right to refuse treatment, they do not have automatic right to demand treatment; they cannot insist that resuscitation must be attempted in any circumstances”

European Resuscitation Council, Resuscitation Guidelines 2005

If general medical opinion considers a particular treatment futile (not altering the patient’s immediate survival nor offering any advantage over alternative treatments), then this alternative need not be performed or even discussed with the patient and/or his surrogate (1990, p. 952). American College of Chest Physicians and the Society of Critical Care Medicine’s Consensus Panel published “Guidelines for the Initiation, Continuation, and Withdrawal of Intensive Care.”


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Unilaterally taking the treatment option off the table for discussion or unilaterally refusing to provide it— when there are real potential value conflicts at stake—can no longer be an acceptable answer.

Rubin SB. If We Think It ’ s Futile , Can ’ t We Just Say No ? HEC Forum. 2007;19:45–65.


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Futility: Fair Process Approach

[Council on Ethical and Judicial Affairs A medical A. Medical Futility in End-of-Life Care: Report of the Council on Ethical and Judicial Affairs. JAMA: The Journal of the American Medical Association. 1999;281(10):937–41. 28-12-2011 Sree/Futility&DNR 16 Dr.S

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FAIR PROCESS APRROACH to futility involves futility judgement on a case by case basis, taking in to consideration all the above three types of futility.In this professional standards and outcome measures incorporated with patient rights, intent standards and family or community involvement by a process of deliberation.The mediator of the fiar process approach is a regulatory body representing community members, physicians and hospital.�(see figure for the fair process approach).��STEPS IN FAIR PROCESS APPROACH:�1. DELIBERATIONS of values before the critical stage and to ascertain what is futile and what is not futile between the physician and patient/SDM. If no agreement, transfer care to another physician�2. JOINT DECISION: If both physician and patient/SDM agree then persue agreed action. If not then...�3. CONSULTANT INVOLVEMENT: Assistance of another consultant with or without patient representative to reach consensus. If this step fails...�4. INSTITUIONAL COMMITTEE: to resolve.�If instituional comiitee decision is against physician, transfer care to another consultant. If against patients, then transfer to another hospital. If no other hospital then persue committes decision, keeping the possible legal consequneces in mind.��

Do-Not-Resuscitate Order (DNR)

Definition: Alternative terms: DNAR; AND

Bishop JP, Brothers KB, Perry JE, Ahmad A. Reviving the conversation around CPR/DNR. The American journal of bioethics : AJOB [Internet]. 2010 Jan [cited 2011 Dec 23];10(1):61–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20077345


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DNR is considered as a "patient order" to the docotr not to resusciate in certain situations, abscence of such an order from patient to the physician interpret as a consent for the invasive CPR

DNR: Policy

Purpose: Limit unnecessary CPR based on Futility In-hospital survival: 13% Out of Hospital survival: 1% Protect physician Withholding treatment Instituting treatment

Tomlinson T, Czlonka D. Futility and hospital policy. Hastings Center Report. 1995;25(3):28–35.

Ewy GA. Cardiac Resuscitation — When Is Enough Enough ? New England Journal of Medicine. 2006;355(5):510–2. 28-12-2011 Sree/Futility&DNR 18 Dr.Sree

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Resuscutation is probably the only intervention in medicine that need consent before withholding it.�Hospital Futility policies are set of directions to the physicians to decide the futility in a given patient to impelment DNR order after informing the patient or SDM. A consent is required, if not lead to ethical committe consideration.�The Futility policy is more paternalistic than DNR policy as in the former, the physician asumes more authority, though with in the frame work of the policy, to implement DNR and there is a possibility for the patient autonomy to undermine. Withholding treatment is a legal liability , equally liable is instituting treatment against patient wishes and preferences

CPR if no DNR order Communication on End-of-Life issues Estimation of Futility Assessment of Values & Goals Paternalism vs Autonomy

DNR Policy: Limitations

Hackler C. It ’ s Bigger Than CPR and Futility : Withholding Medically Inappropriate Care It ’ s Bigger Than CPR and Futility : Withholding Medically Inappropriate. The American Journal of Bioethics. 2010;10:70–1.


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Generally, in most if not all of the hospitals, the policy written or unwritten is the presuming consent for CPR when a patient arrest than allowing for "Allow for Natural Death" that is historically rooted in the naive optimism that death is avoidable.

DNR : Process

S= Subjective values of the patient / SDM O=Objective data gathered by physician A= Assessment putting the S & O together P=Plan of intervene or not.

Rubin SB. If We Think It ’ s Futile , Can ’ t We Just Say No ? HEC Forum. 2007;19:45–65. 28-12-2011 Sree/Futility&DNR 20 Dr.S

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Assessment of futility and consequent decision on DNR is controversial because of the difficulty to answer the question:�Does Futility and DNR is a pure medical decision or moral decision based on patients values? �You can argue on any one side of this, the former empower physician, the latter empower patient/SDM.The former argue for physican autonomy and the later patient autonomy.�Majority of physicians wish for a peacful death and prefer their patients also to die peacefully does not mean all patients values are similar to this. Some may opt to fight the last moment, as they used to be in theie past life, if so that should be respected and granted.��For example, imagine two 52 year-old breast cancer patients with exactly the same diagnosis and prognosis. One has a daughter who is due to give birth to the patient’s first grandchild and her goal is to survive to see that day and hold that baby. The other patient saw her sister die a long and agonizing death of the same cancer and her goal is to have as quick and painless an end as possible. Aggressive measures might be indicated for the first patient and contraindicated for the second patient, based not on the “O,” the objective data, but rather on the “S,” the who they are subjectively and what their goals are.��A decision whether to live or not and if living then with what quality is obviously not a medical decision but a moral decision. When it is a moral decision, then it is the patient who is empowered to take decisions and not physicians.�When there is a conflict betwen physican and patient on futility, the question to ask themselves to resolve the dilema is:�“Futile with respect to what goal, and whose goal is that?” This specify the nature of actual disagreement and offer far meaningful to discuss whether treatment in question is futile or not.�Most of the studies where the effectiveness of CPR is assessed, the outcome is discharge home. Quantitative futility estimation based on these studies may not hold ofr an indivual patient who value to stay few more days in the hospital itself for one or other reason.��A DNR decision where futility as estimated by the patient based on her values and the futility that is estimated by the physician based on the literature data are taken in to consideration is the most acceptable one for both physican and patient and that is least likely to draw disputes to the ethical committe or courts to solve.�The steps to consider are:�S= Subjective values of the patient / SDM�O=Objective date gathered by physician�A= Assessment putting the S & O together�P=Plan of intervene or not.�This is possible only if the physican find the S and the O at the early part of a termianl encounter than when the arrest or deterioration occurs.

DNR Policy: Process 1. Education of patient/SDM: 2. Estimate success of CPR in that patient 3. Evaluate potential QOL after successful CPR 4. Problems of instituting CPR 5. Time for reflections

Kind V. Case Study CPR and DNR Decision Making. Age in Action. 2010;:1–5.


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How many of you are would like to have Debfrillation and intubation with cardiac compression at the time of last breath?��Process of DNR decision making:�1. Education of patient/SDM: What is CPR means.�2. Estimate sucess of CPR in that patient (over all 17%; patients in ICU with sepsis almost none; patients with priamry cardiac event leading to arrest: excellent)�3. Evalaute potential quality of life after successful CPR�4. Problems of instituing CPR: pain, fracture rib, lack of peacful death�5. Time for reflections: decision not by SDM but by them the decision that the patient could have taken.(to avoid feeling of guilt)��AND : Allow Natural Death is a gentle way to express DNR; DNR is nothing but a peaceful or dignified way of dying.�

DNR Policy

“Slow code” “DNR without Consent” “Futile DNR”

David P Eisenman. DNR orders and Medical Futility. Journal Of The American Medical Association. 1995;274(4):299–300. Luce JM. Clinical Commentary Making Decisions About the Forgoing of Life-sustaining Therapy. Critical Care Medicine. 1993;:1–4. Truog RD. Is it always wrong to perform Futile CPR? New England Journal of Medicine. 2010;362(6):477–9.


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1.Institutions where there is no expert ethical committee and physcians are not confident of determining the medical futility, the "slow code" becomes the predominant method of limiting inappropriate use of CPR. 2. Withdrawing or withhelding life sustaining treatments in ICU without patients advances directives or SDM consent is common in states�Slow code is a resuscitative effort without the intention of therapeutic benifit for the patient.�The purpose is mainly to avoid potential legal risk of not impelmenting CPR, even if it is futile on medical grounds. 3. Futile CPR may have to be performed in exceptional cases to minimize the psychological trauma of the surviving surrogates.�"Although the interests of the patient are always primary, at the end of life there are times when the interests of the patient begin to wane, while those of the family intensify."��If medical futility established but patient unable to consent for DNR and relatives refuse DNR, the resuscitation at such circumstances is not only futile but brutal to satisfy the relatives that "everything possible done". Here the physician act at the interest of the surviving relatives to minimize the future psychological trauma, at the risk of inciting pain and discomfort instead of peace and comfort at the moment of death.

DNR: Islamic perspectives

"Anyone who has saved a life, it is as if he has saved the life of whole

mankind" (5:32).


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Holy Quran says, "Anyone who has saved a life, it is as if he has saved the life of whole mankind" (5:32).

DNR: Islamic Perspectives

Purposes of Law: 1. Certainty of Futility: 2. Preservation of life (ḥifẓ al-nafs): 3. Consent: 4. Abuse: Kasule OH. DNR: An Islamic Formulation. Journal of Islamic Medical Association. 2010;42(March):36–7.


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Ismalic laws and DNR decisions:�Based on the five purposes of the law (maqāṣid al-sharī`a) islamic laws does not prohibit DNR.�1. Certainity of Futility:�A DNR order is lagally valid if certainity exists that CPR is futile.The second level of certainity Islamic law recognize is ghalaba(t) al-ẓann (predominant conjecture) for that four physicans equivalent to jama(a community) is necessary to take decisions on this ground.�2. Preservation of life (ḥifẓ al-nafs) balance with preservation of resources( ḥifẓ al-māl) but always the former take precedence. But when certainity of life is abscent, the former take precedence.�3. Consent: Under the prinicple of preventing harm (lā ḍarar), consent is required, just like any other medical decisions that is associated with potential harm require consent.�4. Abuse: Actions should be judged by intentions (al-qaṣd) and the DNR decision should be based on the intention of serving the patients/ SDM values and goals.


The Presidency of the Administration of Islamic Research and Ifta, Riyadh, Kingdom of Saudi Arabia (KSA): Fatwa No. 12086

Saleem Saiyad. Do Not Resuscitate: A case study from islamic view point. Journal of Islamic Medical Association [Internet]. 2009 Jan;41:109–13

Takrouri MSM, Halwani TM. An Islamic Medical and Legal Prospective Of Do Not Resuscitate Order In Critical Care Medicine. The Internet Journal of Health. 2008;7(1).


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Holy Quaran:�"No soul can die except by Allah’s permis- sion"�Shariah:Defitniion of death:��1. When the heartbeat and breathing stop completely, and the doctors decide that they cannot be restarted.OR �2. When all the functions of the brain stop completely, experienced doctors and special- ists confirm that this is irreversible and the brain (as a whole) has started to disinte- grate.��The Presidency of the Administration of IslamicResearch and Ifta, Riyadh, Kingdom of Saudi Arabia (KSA), in its Fatwa No. 12086 issued on 30.6.1409(Hijra) [1988 (AD)],18�stated:�If three knowledgeable and trustworthy physicians agreed that the patient condition is hopeless, the life-supporting machines can be withheld or withdrawn. The family members’ opinion is not included in decision making as they are unqualified to make such decisions. (translation by Takrouri and Halwani)��In a Hadith, narrated by Anas bin Malik, the Propheﷺ, said:"None of you should wish for deatht because of a calamity befalling him; but if he has to wish for death, he should say: “O Allah! Keep me alive as long as life is better for me, and let me die if death is better for me.”��


Out of 659 neonatal admissions in Oman (RH), 39 (6%) parents

consented for DNR.

da Costa DE, Ghazal H, Al Khusaiby S. Do Not Resuscitate orders and ethical decisions in a neonatal intensive care unit in a Muslim community. Archives of disease in childhood. Fetal and neonatal edition [Internet]. 2002 Mar;86(2):F115–9.


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Aims: To evaluate the need for Do Not Resuscitate (DNR) orders in a tertiary referral centre for neonatal intensive care, the criteria used in making these decisions, and the applicability of the Muslim ethical stance among parents in an Islamic community. Methods: A prospective evaluation of all DNR decisions in the neonatal intensive care unit at the Royal Hospital in Oman, over a one year period between November 1999 and October 2000. This included decision criteria, and parental responses and expectations. Results: Of 659 admissions to the neonatal intensive care unit during this period, DNR orders were written in 39 (6%) instances. Most related to congenital malformations (24/39, 62%). In those in whom ventilation was commenced (19/39, 49%) withdrawal was not culturally acceptable and expressly permitted in only 11%. For those in whom ventilation was not commenced (20/39, 51%), 70% agreed not to put their child on the ventilator if they did require it. Presence of extended family support (grandparents) and clergy was extremely useful. Conclusions: Asking parents alone to be explicitly involved or take full responsibility for decisions involving life and death is not culturally or socially acceptable in this community. Presence of extended family, and indirectly sounding out and taking into account their wishes, is more appropriate after assessing the resources and support services available.

DNR Policy: RH


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Medical Futility & Do-Not-Resuscitate Medical Futility: Definition Types Purposes Limitations Estimation Process Do-Not-Resuscitate Orders: Definition Purpose Limitations Process Plicies: RH/SQUH DNR: Islamic perspectives :


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