Towards a modified cardiopulmonary resuscitation policy.

This article proposes a modification of a hospital cardiopulmonary resuscitation (CPR)/do not resuscitate (DNR) policy that prescribes CPR for all unless a DNR order is agreed to by patient and physician. Rather than maintaining CPR as an intervention that can be avoided only by a negative order, the proposed modified policy supports a positive order, i.e., perform CPR when beneficial unless the patient refuses. To provide a clinical basis for an ethical discussion comparing the current policy with the modified proposal, a brief review of the outcome of CPR in terms of survival to discharge is presented. Two principal observations were made. First, regarding overall survival, there is an element of harm for an important proportion of those who initially respond to CPR but fail to survive to discharge, spending time in the intensive care unit only to have a subsequent arrest and death in hospital. Second, a set of point estimates of survival to discharge in relation to 11 pre-arrest diagnostic characteristics shows their close correlation. The modified proposal should provide a more realistic framework within which to evaluate the needs and wishes of patients at this difficult and emotional time. This concept is implemented by establishing the CPR status of all patients as one component of their positive treatment regimen, rather than having CPR as an intervention to be avoided only by the DNR order. The author discusses the current and proposed policy relative to their effect on patient selection, discussion with patients about CPR, the dilemma that results when the patient insists on CPR when it is not recommended and the protection of patient autonomy.