DNR policies in healthcare organizations with emphasis on hospice.

Abstract

In thepastseveralyears,intensive interest has focusedon the complexities of the do-not-resuscitate (DNR) treatmentdecision. Most recently, the President’sCommission for the Study of Ethical Problemsin MedicineandBiomedical andBehavioralResearch1raised thefollowing threecritical pointsin referenceto DNR. First, resuscitation is a very painful and intrusive procedure.Second,efforts to resuscitate a dying patientare only successfulin approximatelyone-inthreeattemptsandof thosepatients who survive initial resuscitationefforts, only one-third are eventually discharged.Thosewho wereable to return homeare often significantly impaired. Finally, the successof resuscitationefforts is generallydifficult to assesswithout carryingout the full rangeof procedures. These facts suggestthat physicians who carry out less aggressiveeffortsbecausetheydid not thoroughlyconsider the resuscitationdecision aheadof the time maynot be acting in their patients’bestinterest. Basedon their deliberations,the President’sCommissionmadethree chief recommendationsfor the developmentof DNR policies.1) Hospitals should developexplicit policies: “on the practiceof writing andimplementingDNR orders.”2) Hospital policies should recognize theneedfor balancedprotectionof patients,and respectthe right of a competentpatient to make an informed choice.3) Hospitalpolicies should provide a means for appropriateresolutionof conflicts,and also mandateinternalreview. In addition to these broad guidelines,the report noted that much of medicalpractice is now governedby private and independentorganizationssuch as the Joint Commissionon Accreditation of Healthcare Organizations (JCAHO) that: “bear a responsibilityto encouragesounddecisions