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CMAJ - July 14, 1998JAMC - le 14 juillet

Hospital's DNR guidelines 2 years in making

CMAJ 1998;159:11

© 1998 Heather Kent

After 2 years of study, the Vancouver Hospital and Health Sciences Centre has issued do-not-resuscitate guidelines that it hopes will steer staff in the right direction when CPR is being considered for dying patients. A brochure, This is Not E.R.!, has been distributed throughout the hospital's clinical practice units.

The initiatives began after staff told the hospital's ethics committee that they were uncomfortable with the existing practice of using CPR in every case. In the 40 years since CPR was introduced, says committee chair Dr. Charles Wright, it is "very bizarre" that its use has become so widespread among terminally ill patients. Fear of litigation if everything possible is not done to revive a patient is "absolutely not an issue," says Wright. "Nobody was ever successfully sued for failure to bring a patient back from the dead." Moreover, he says, it is "not ethical for physicians to prescribe treatment that they know to be useless and potentially very harmful."

The committee reviewed about 2000 files and found that only 50% of those that should have included DNR orders actually did. Wright says a literature search revealed that the use of CPR for patients with chronic illnesses other than heart disease produced "dreadful" results. Even in cases of acute coronary disease, CPR enjoyed only a 20% success rate. Accordingly, the guidelines recommend against using CPR for patients experiencing an unwitnessed cardiac arrest, or for those dying of metastatic cancer or other incurable diseases. When resuscitation is attempted it should stop after 20 minutes. Once that time limit is surpassed, says Wright, the chances of success "drop rapidly to zero and the chance of brain damage soars."

He encourages doctors and nurses to speak openly to patients for whom resuscitation is contraindicated. "A doctor needs to say ‘this technique of CPR in your circumstances is not a treatment that has any value, and it has serious potential problems.' The great majority of patients say their worst fear is being hooked up to tubes and ventilators." Wright adds that the small, vocal minority who want everything possible done to save life represent a "basic denial of death."

The committee will follow up on the effectiveness of the guidelines through a questionnaire that assesses staff comfort levels and by sampling the numbers of DNR orders written.

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