Hospital policies typically require that cardiopulmonary resuscitation be attempted unless a do-not-resuscitate order has been written, and they further require that family permission for the order be obtained. This sometimes forces physicians to perform procedures that are useless or that add to the patient's suffering without corresponding benefit. Policies should be changed to allow physicians to write a do-not-resuscitate order over family objections when (1) the patient lacks decision-making capacity, (2) the burdens of treatment clearly outweigh the benefits, (3) the surrogate does not give an appropriate reason in terms of patient values, preferences, or best interests, and (4) the physician has made serious efforts to communicate with the family and to mediate the disagreement. Furthermore, when resuscitation would clearly provide no medical benefit to the patient, policy should not require that it be discussed with either the patient or the family.
KIE: The authors call for reform of hospital policies that now require family permission before a do-not-resuscitate (DNR) order may be written for patients who are not competent to give consent themselves. Hackler and Hiller report two cases where the lives and suffering of dying patients were prolonged when family members insisted upon cardiopulmonary resuscitation (CPR) despite hopeless prognoses. They argue that the authority of family members to make treatment decisions is limited when neither patients' preferences nor best interests are served. They propose that hospital policies concerning resuscitation be changed so that: 1) the option of futile resuscitation need not be offered to patients or family members, and 2) family agreement to CPR need not be obtained in every case where the procedure is not clearly futile.