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Table of Contents
REVIEW ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 8-12

Can a patient or physician refuse cardio pulmonary resuscitation?


Professor of Clinical ethics and Medicine, Head of Department of Family Medicine, St. John's Medical College, St. John's National Academy of Helath Sciences; Department of Family Medicine, St. John's Medical College, Bengaluru, Karnataka, India

Date of Submission24-Nov-2020
Date of Decision18-Feb-2021
Date of Acceptance24-Feb-2021
Date of Web Publication06-Jan-2022

Correspondence Address:
Dr. G D Ravindran
Department of Medicine, 5th floor, St. John's Medical College Hospital, Sarjapur Road, Bangalore - 560 034, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajim.ajim_92_20

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  Abstract 


ICMR released guideline “Do not attempt resuscitation” in the month of April 2020. This article explores the ethical principles that underlie this guideline. The ethical principles involved are autonomy, futility, ordinary/extraordinary means, principle of double effect, and principle of Good Samaritan and the legal provisions are discussed. It summarizes the process of implementing the guidelines and problems that are involved in its implementation.

Keywords: Do not attempt to resuscitate, ICMR guidelines, ICMR Guidelines Resuscitation


How to cite this article:
Ravindran G D. Can a patient or physician refuse cardio pulmonary resuscitation?. APIK J Int Med 2022;10:8-12

How to cite this URL:
Ravindran G D. Can a patient or physician refuse cardio pulmonary resuscitation?. APIK J Int Med [serial online] 2022 [cited 2022 Jan 24];10:8-12. Available from: https://www.ajim.in/text.asp?2022/10/1/8/335087



Terminal event, that is, seen in all patients is cardiorespiratory arrest. It was in 1960 Drs. Kouwenhoven, Safar, and Jude described cardiopulmonary resuscitation (CPR) as a modality of treatment for cardiac arrest.[1],[2] It is an emergency procedure performed in an attempt to revive patients suffering from cardiac and/or respiratory arrest. It involves either or all of the following: Repeated chest compression; mouth-to-mouth or artificial breathing usually with intubation and ventilator. Sometimes patients may undergo defibrillation or drugs may be injected intravenously.[3]

Today, this has become a standard of care for patients who are dying irrespective of the disease process. The survival of patients after CPR is dismal. Various studies have shown that survival 6 months after CPR is around 15%.[4] Not performing CPR on a dying patient may be construed as medical negligence. In certain situations, however, providing CPR is likely to increase the suffering of patients who have serious often terminal illness and without the prospect of a reasonable quality of life even if they are revived, especially in patients who have terminal conditions such as malignancy. Since it is an emergency procedure consent is implied and the physician does not obtain an informed consent. Can a patient refuse cardiac resuscitation before the act has occurred? This article will try to answer the ethical and legal aspects as well as the recent ICMR guidelines.


  Ethical Issues at the End of Life Top


Ethical principles that are involved at the end of life are:

  1. Autonomy
  2. Futility
  3. Ordinary versus extraordinary means
  4. Principle of double effect
  5. Good Samaritan.



  Autonomy Top


The ethical basis for refusal of treatment is the principle of patient autonomy. A competent person is capable of deciding the best course of action for their welfare. The decision must be made with full exercise of the knowledge on the consequence of the decision. This entails that the patient the right to decide about continuance and discontinuance of life-supporting treatments at the end of life. The patient has the right to refuse unnecessary advanced technological interventions that prolong the dying process. It also entails that the patient can anticipate that she/he will obtain o relief from pain and suffering at the end of life and die with dignity. An advance directive will help to achieve this objective.

Legal provisions

The Constitution of India guarantees the Right to Life (art 21). This right does not give a right to end of life. Numerous court rulings have ruled against euthanasia. In India active euthanasia is illegal and a crime under section 302 or at least section 304 IPC. Physician-assisted suicide is a crime under section 306 IPC (abetment to suicide).

In a landmark judgment in Aruna Ramchandra Shanbaug[5] the 2011 the Supreme Court laid down the procedure to discontinue treatment. Justice Markandya while delivering the judgment stated “we are laying down the law in this connection which will continue to be the law until Parliament makes a law on the subject.” This conclusion was based Article 226 of the Constitution which can grant approval for withdrawal of life support to such an incompetent person. The parliament has not passed any law on this subject.


  Futility Top


A disease may progress to a stage when medical interventions will not offer any alleviation of the medical problem. We can expect the patient will die. During that time the medical profession has to offer compassionate care to the patient. When a treatment applied to a particular patient fails to achieve medicine's goals, then that treatment is not beneficial to the patient then the treatment can be considered as futile. There is no objective evidence to say when a treatment is futile. Many ethicists have used an empirical standard of the previous experience of treatment of patients in similar situations. If they find that in their experience that the use of the intervention in 95% of patients is not effective then it is termed a futile intervention. Patients have a right not to receive a futile intervention and similarly, the doctor does not have a duty to provide futile interventions.


  The Principle of Ordinary Means and Extraordinary Means Top


“Ordinary means” is defined as are all interventions that offer a reasonable hope of benefit for the patient and/or which can be obtained or used without excessive expense, pain or burden. If the treatment is considered ordinary then the health care providers, hospitals, or government have an obligation to provide it to the patient.

Extraordinary means of treatment are all interventions that cannot be used or obtained without excessive expense, pain, or other burdens. If they are deemed extraordinary they may not be employed and health care does not have an obligation to provide. The concept of extraordinary and ordinary is a dynamic concept. Interventions that were considered extraordinary in the past today are considered as ordinary, for example, the use of defibrillators.


  Principle of Double Effect Top


One other principle that is used in the care of the dying is the principle of double effect. To apply this principle for an action these conditions need to be fulfilled. The nature of the act must be good in itself. Person performing the act must intend only the good effect and should not intend the bad effect either as a means to the good or as an end in itself. The good effect outweighs the bad effect in circumstances sufficiently grave to justify causing the bad effect and the agent exercises due diligence to minimize the harm. For example., sedation of a terminally ill patient.


  Principle of Good Samaritan Top


The traditional common law does not require a person to help another person in distress if that person is not obligated to the injured person. Once a person helps the injured person she/he can be held liable for any harm they will do. As opposed to this concept we have a concept of Good Samaritan. The term Good Samaritan is derived from the Bible. A Samaritan man who was passing a person injured in a robbery attempt helped the person when his own community members did not help him.

To apply this concept for physician actions in emergency conditions certain conditions have to be fulfilled. A physician must not have a duty to treat and she/he should not receive any compensation for the services that she/he has rendered. It excludes the treating physician and physicians who are on-call duty as they are compensated for their duty. Often when a cardiac arrest occurs in the wards, often resuscitation is initiated by any person who is in the ward often nursing personnel. There is no time to obtain consent, in this situation concept of the good samaritan is applied for resuscitation. A treating physician can do resusticiation on the principle of implied consent.


  Legal Provisions Top


The Karnataka Government has passed legislation in 2016 that was amended in 2018 as “the Karnataka Good Samaritan and Medical Professional (Protection and Regulation during Emergency Situations) (Amendment) Act, 2018.”[6] This is the first act passed in the country to protect health care workers and people who help in emergencies. This protects the HCW from any civil or criminal liability for any act or omission that is done with good faith while providing emergency care. It defines a good Samaritan as a person who in good faith voluntarily comes forward to administer emergency care without any consideration. The act gives liability protection against “ordinary negligence.” Ordinary negligence is the failure to act as a reasonably prudent person would act. It does not protect against gross negligence. It also provides protection to medical professionals during their examination as a witness in case of emergency treatment. Apart from the health care worker, the act also provides protection to people who help the patient in an emergency.

With Aruna Shanbag case the Supreme Court in 2009 laid down the procedures for discontinuing life-sustaining treatment. The procedure is cumbersome and not practicable. The same judgment urged the lawmakers and parliament to pass laws for the care of the terminally ill. Since the Parliament has not taken cognizance of this issue, doctors working in palliative care are forced to do CPR even when they know that it is futile, painful, and not in tune with the patients wishes.


  Is there Passive Euthanasia? Top


Indian health care is oriented to the cure mode and not in care and comfort mode. As a result of this attitude, we confuse withholding or withdrawal of treatment with euthanasia. Some people have designated this as passive euthanasia. ICMR in its document on glossary[7] condemns the use of term passive euthanasia. Withholding or withdrawal of life sustain treatment is not passive euthanasia. Countries that have advance medical facilities do not use this term. Similarly, the Supreme Court of India has stated “The term passive euthanasia is an obsolete terminology and should be avoided as euthanasia cannot be passive and withholding or withdrawing of potentially inappropriate treatment in a patient dying with terminal illness that only prolongs, the dying process cannot be construed as an intention to kill. Furthermore, it emphasizes, “…allowing natural death, withholding and withdrawing life-sustaining treatment to limit harm and suffering in a dying patient should not be construed as euthanasia.” In the fifties of the last century Dame Cicely Saunders expressed strong opinions against euthanasia. She felt that it is always possible to control pain. She felt that palliative physicians must use their knowledge to prevent pain and distress toward the end and there is nothing like passive or active euthanasia.


  Do Not Attempt Resuscitation Top


To deal with these situations the ICMR has released a guideline Do not attempt resuscitation (DNAR) in the month of April 2020.[8],[9] It is not an advanced directive. It only deals with terminal resuscitation. It is an option that may be exercised by the treating physician in such a situation in the best interests of the patient.

DNAR relates to CPR only and its limited value in certain situations and not in other forms of treatment. Whenever the treating physician is in doubt on whether to perform DNAR or not, CPR should be performed as the default option [Figure 1].
Figure 1: Algorithm for Do not attempt resuscitation

Click here to view



  Indications for Do Not Attempt Resuscitation Top


DNAR would apply to a patient with a progressive debilitating/incurable/terminal illness where CPR would be inappropriate, nonbeneficial, and likely to prolong the suffering of the patient in the best judgment of the treating physician(s). Compassionate care is integral to the overall goals of medical treatment.


  How Does a Physician Obtain a Do Not Attempt Resuscitation from the Patient? Top


Once the treating team decides that the patient is in terminal stages and it has been decided to provide palliative care and comfort, there is a need to discuss the need for DNAR orders. The patient with family and surrogate decision-maker must be counseled. During the counseling treatment and prognosis of the condition must be emphasized. A discussion of benefits and harms of CPR must be discussed. The patient must be given a realistic picture of the condition. The counseling must be done by the treating physician and not be left to others in the team.

Patients and their families must be given adequate time and opportunity to discuss these issues among themselves and with the treating team. The treating team must ensure that the patient and his family have understood the consequences of their action. The patient and his family must be assured that all treatment will be continued till the patient undergoes cardiac arrest. Only on that event will this be acted upon.

Once, the patient has decided the decision must be documented and it has to obtain in writing. The patient or legally authorized representative must sign and the document. It needs to be witnessed. A standard format is provided in the guidelines. It must be translated into simple local languages. A copy of the DNAR must be attached to the case file. The original document must be archived and preserved.


  Dispute Resolutions Top


If the treating physician is unsure about the futility of CPR or there is no consensus between the treating team patient and family, the guideline advocates a combined decision to be made with the help of another physician, a psychologist or social worker, or a counselor or the hospital administrator.


  Problems with Do Not Attempt Resuscitation Top


This guideline has opened a new possibility in patient care. The treating and palliative care teams have to offer these options to the patients and their families.[10] Patients may feel that they are abounded by their physicians. Physicians and their teams need to be trained in the implementation of the DNAR. At present, there have been no efforts by any of the agencies or associations to impart training.

Often the CPR is initiated by the nursing personnel and managed by code blue teams. The treating physician must convey this information to the nursing as well as code blue teams. During code Blue, the team does not have time to go through the case records. The guideline is not very clear on this aspect. Maintaining patient confidentiality is another issue. The treating team has to ensure that regular career is not compromised and accused of breach of confidentiality.


  Future Developments Top


Supreme Court on March 18, 2018[11] delivered a judgment that will have a major impact on the end of life care in India. It held that article 21 the Right to life also includes the Right to die. An individual has the Right to die with dignity as a part of the Right to life. It permits discontinuation of life support systems in terminal cases of the incurable disease. It permitted an individual to decide against artificial life support. It also recognized the need for creating living wills. In light of this judgment, there will be new rules and laws that will guide the future.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA 1984;251:3133-40.  Back to cited text no. 1
    
2.
Jude JR. Personal reminiscences of the origin and history of cardiopulmonary resuscitation (CPR). Am J Cardiol 2003;92:956-63.  Back to cited text no. 2
    
3.
Nolan JP, Maconochie I, Soar J, Olasveengen TM, Greif R, Wyckoff MH, et al. Executive Summary: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020 Oct 20;142(16_suppl_1):S2-S27. doi: 10.1161/CIR.0000000000000890. Epub 2020 Oct 21. PMID: 33084397. [Last accessed on 2021 Jan].  Back to cited text no. 3
    
4.
Stapleton RD, Ehlenbach WJ, Randall Curtis J. Long-term outcomes after in-hospital CPR in older adults with chronic illness. Chest 2014;146:1214-25.  Back to cited text no. 4
    
5.
Supreme Court of India Aruna Ramchandra Shanbaug vs Union of India and Ors on 7 March, 2011 Reported in Indian Kanoon. Available from: http://indiankanoon.org/doc/235821/. [last accessed on 2020 Oct 27].  Back to cited text no. 5
    
6.
Good Samaritan and Medical Professional (Protection and Regulation during Emergency Situations) Act, 2018. The Karnataka Gazette Extra-Ordinary on the Twenty Third Day of January, 2019. Available from: https://prsindia.org/files/bills_acts/acts_states/karnataka/2018/2018KR26.pdf. [last accessed on 2020 Oct 27].  Back to cited text no. 6
    
7.
Definition of Terms Used in Limitation of Treatment and Providing Palliative Care at End of Life. Available from: https://ethics.ncdirindia.org//asset/pdf/Definition_of_terms_used_in_limitation_of_treatment_and_providing_palliative_care_at_end_of_life.pdf. [last accessed on 2020 Oct 27].  Back to cited text no. 7
    
8.
Mathur R. ICMR consensus guidelines on 'Do Not Attempt Resuscitation'. Indian J Med Res 2020;151:303-10.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Mathur R. ICMR consensus guidelines on 'Do Not Attempt Resuscitation'. Natl Med J India 2020;32:e1-8.  Back to cited text no. 9
    
10.
Timms O. DNAR guidelines: Supporting end-of-life decisions. Indian J Med Ethics 2020;5:180-1.  Back to cited text no. 10
    
11.
Supreme Court of India Civil Original Jurisdiction Writ Petition (Civil) No. 215 of 2005 Common Cause (A Regd. Society)… Petitioner(s) Versus Union of India and another Respondent Indian Kanoon. Available from: http://indiankanoon.org/doc/184. [last accessed on 2020 Oct 27].  Back to cited text no. 11
    


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  In this article
Abstract
Ethical Issues a...
Autonomy
Futility
The Principle of...
Principle of Dou...
Principle of Goo...
Legal Provisions
Is there Passive...
Do Not Attempt R...
Indications for ...
How Does a Physi...
Dispute Resolutions
Problems with Do...
Future Developments
References
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