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written by Professor Dr. Omar Hasan Kasule Sr.
1.0 DEFINITION OF TERMS
Discussion
of DNR requires clarification of basic terms: terminal illness, end of life,
death, euthanasia, resuscitation, withholding, withdrawal.
Terminal
illness, maradh al mawt, is illness from which recovery is not expected.
The definition is based an empirical probability estimation reflecting experience
of similar patients in the past who succumbed to their disease. Being a
probability statement, terminal illness does not apply to all patients.
End
of life / approaching the end of life: This term is used to refer to patients
likely to die soon (days to a few months).
Death
process: death is not an event but a process with a time line that may be long
or short. An established death process is progressive failure of the
cardio-respiratory system. The process once established is irreversible. The
process is picks up momentum as death approaches. Death from whatever cause has
a common final path: cardio-respiratory failure which means denying cells and
tissues perfusion of oxygen and nutrients necessary for cell metabolism. Brain
tissue being the most sensitive to oxygen and nutrient deprivation will die
first. There is however a chicken and egg argument here. If the brain dies
first, the cardiorespiratory system will die soon after because its coordinated
function requires that some brain centers remain active and alive. It is very
important to know the point of irreversibility of the death process because
interventions beyond this point are futile. The examples of conditions normally
cited can be classified into two categories: (a) established death process (b)
pre the death process.
Euthanasia
is an act of commission or an act of omission that hastens death with the aim
of saving the patient from pain or further suffering, physical or
psychological.
Resuscitation:
is a series of medical measures taken to reverse cardio-respiratory failure. The
term CPR should be avoided because it can have two meanings: (a) traditional
chest compressions and oxygenation (b) all measures of reviving cardiac and
respiratory function both basic and advanced.
DNR
in some countries is a normal clinical decision based on facts that should be
disclosed to the patient or a substitute decision maker to obtain informed
consent
DNR
in KSA is a clinical decision with no input from the patient or substitute
decision maker. There is a requirement to just inform the family.
Paternalism
is an attitude of physicians that they know what is best for the patient and
therefore make decisions without respecting the patient’s autonomy
Futility
refers to medical interventions that will not have a nett and lasting impact on
cardio-respiratory decline. Survival after CPR is generally low 15-20% (BMA
Guidelines 2007). The process may have its risks like rib fracture. Survivors
may have brain injury due anoxia before restoration of cardio respiratory
function.
Withholding
life support means not starting any artificial and radical cardio-respiratory
support measures in a patient deemed to be in an established death process. Withdrawal
of life support means stopping some or all artificial cardio-respiratory
support measures that may be followed by death of the patient.
2.0 CANDIDATE CONDITIONS FOR DNR
2.1 Criteria
vs examples
In order to define what procedures are
involved in DNR we need to have a consensus on what conditions qualify for DNR.
It is not possible to produce criteria for conditions that qualify for DNR
because they would be very difficult to operationalize. Most often examples are given as guidelines. There
is therefore wide variation among consultants in DNR decisions.
2.3 Examples
from KFMC CPP No 1430-60
1. Advanced incurable malignancy, 2. advanced
multi-organ failure, 3. irreversible, severe, and documented brain damage 4. advanced
cardiac, hepatic, or pulmonary disease 5. ioperable, life threatening congenital
heart disease, fatal chromosomal or neuromuscular disease 6. Irreversible,
severe, mental and physical incapacity.
2.2
Examples from ARAMCO
1. Advanced incurable, end-stage malignancy
2. End-stage organ failure 3. advanced irreversible brain damage 4. end-stage
renal disease if renal replacement therapy is not feasible 5. Inoperable
congenital anomalies incompatible with life 6. Fatal chromosomal abnormalities
7. brain death.
3.0 PRE-DEATH AND ESTABLISHED DEATH PROCESS
3.1
Established death process
A DNR order for a condition within the death
process is understandable because of the futility in reversing the
cardio-respiratory collapse. If resuscitation is attempted, the patient will
recover for a short time and succumb again the only other alternative being
maintaining artificial life support for an indefinite time with no hope of
recovery.
The DNR order for such cases is usually a
short time before final death because these conditions can only be ascertained
for patients already in the death process.
The KFMC CPP is appropriately titled
‘Allowing Natural Death’ because these patients are already in an irreversible
trajectory to certain death and there is no need for futile artificial
interference.
In a view expressed in another paper, the DNR
order is a normal medical decision based on evidence and informed
consent/assent/no dissent by the patient or the family.
3.2 Pre
the death process
Most of the conditions mentioned in the KFMC
and ARAMCO documents precede but are not part of an established death process. Patients
with these conditions can survive for various periods of time until they
succumb to their illness or to some other illness. Because of the poor
prognosis for these conditions, artificial heroic interference beyond normal
maintenance or supportive treatment of any kind is not appropriate. This
includes CPR in addition to other surgical or medical procedures. These
patients should therefore be not be under the DNR policy but should be covered
by another policy more in the line of palliative or terminal care. They should
also be admitted from the beginning to wards without advanced life support
facilities in the knowledge that these will not be needed. It should be part of
the policy that they are not admissible to the ICU with appropriate
explanations for their families.
Cardio-respiratory collapse in these patients
may be due to the primary condition or may not be but the distinction is only
of theoretical interest because in a situation requiring urgent intervention,
there is no time to ascertain the cause of the collapse. The use of DNR orders for such patients
creates many moral issues that require discussion. The DNR order is not based
on whether they will benefit from the resuscitation or not. It is based on the
presumption that even if they benefit from resuscitation, they will succumb
sooner or later to their disease so the resuscitation is futile. The futility
of resuscitation in this case is related more to the remote outcome and not on
the current cardio-respiratory collapse.
A DNR order can be justified on the basis of
the doctrine of futility but what futility? (immediate cardiorespiratory or the
remote disease outcome).
A DNR order would be illegal if done to save
the patient from further suffering because that would be passive euthanasia.
4.0 DNR WHAT IT COVERS AND WHAT IT DOES NOT
COVER
4.1 Principal
Components of a DNR order
DNR stands for ‘do not
resuscitate’ and is withholding specific
measures that will reverse cardio-respiratory collapse. These measures are
considered heroic and futile for patients in an established death process. They
are useful for patients with cardio-reversible respiratory collapse enabling
them to survive longer for a reasonable time.
4.2
KFMC
The KFMC CPP No 1430-60 mentions
the components of DNR as: bag-mask ventilation, intubation, chest compression,
code medications, and defibrillation
4.3 SAMSO
The SAMSO MSP 102 classifies
components of DNR into two categories. (a) measures that shall be withheld for
DNR patients: cardio pulmonary resuscitation, endotracheal intubation, and
initiation of mechanical ventilation. (b) Measures that may/may not be withheld:
inotropic/vasoactive drugs, admission to ICU/step down unit, renal replacement
therapy (hemo, peritoneal, or continuous hemofiltration), blood or blood
products transfusion, total parenteral nutrition, repletion of tests,
diagnostic or therapeutic procedures that do not contribute to end of life
care, aggressive pulmonary hygiene protocol.
In addition supportive care is
continued during the DNR status: nursing care and cleanliness, clearance of
secretions (oral, nasal, endotracheal etc), water and food, pain management,
supplementary oxygen, iv fluids, enteral feeding, comfort, management of
symptoms, spiritual support.
4.4
BRITISH MEDICAL ASSOCIATION (Guidelines 2007)
The guidelines do not distinguish
between basic and advanced life support measures on the argument that the
ethical issues involved are the same.
Components of DNR: chest
compressions, attempted defibrillation with electric shocks, injection of drugs
and ventilation of the lungs. In some cases spontaneous cardiac function may be
restored with prompt use of an electric shock alone.
4.5 SINGAPORE
An empirical study showed that
measures instituted during DNR were: oxygen therapy (38.9%), nasogastric tube
insertion and feeding (30.6% and 33.3% respectively), intravenous fluid
administration (33.3%), blood investigations (33.3%), opioid use (33.3%) and
antibiotic use (29.2%). Measures withdrawn were intravenous fluid administration
(36.1%), hourly monitoring of parameters (22.2%), antibiotics (13.9%), high
dependency care (12.5%) and nasogastric tube feeding (6.9%).
4.6
SUMMARY
There are basically 3 measures
that can be included in a DNR order: (a) cardiopulmonary resuscitation
involving chest compressions and oxygenation, (b) endotracheal intubation, and (c)
mechanical ventilation. These measures may/may not be applied in the order that
they are given. Clinicians will automatically apply the next procedure if the
first one fails. Additional measures that be included: (d) defibrillation (e)
vaso active /ionotropic medication.
Life support measures not related
to cardio-respiratory support can continue during DNR: renal dialysis, blood
transfusion, parenteral nutrition, pulmonary hygiene, normal treatment eg
antibiotics.
Supportive care during DNR should
continue including: Clearance of secretions (oral, nasal, endotracheal, etc.),
hydration, nutrition, pain management, supplemental oxygen, sedation,
antipyretics, anti emetics, relieve of constipation, relief of urinary
retention, relief of dypnea and cough.
5.0 CONCLUSIONS/RECOMMENDATIONS
5.1 It is difficult to distinguish
between basic and advanced life support measures (al umuur bi maqasidiha)
5.2 To avoid confusion DNR orders
should specify the measures intended
5.3 We need to carry out
empirical research on the DNR process at KFMC: indications, decision process,
outcome (death/survival), family reactions etc.