Health : Letting Go : Experts Say Surge in ‘Do Not Resuscitate’ Orders Reflects Shift in Public’s Attitude Toward Dying

The middle-aged stroke victim lay on her back in the equipment-crammed intensive care unit room at Huntington Memorial Hospital in Pasadena, a respirator keeping her alive.

At a nursing station in the center of the unit--scarcely 20 feet away--supervisor Zorka Barabas glanced at the woman, then at a green-on-black television screen image that tracked her heartbeat in a monitor bank.

In the woman’s room, nurses and technicians hovered at the bedside adjusting equipment and caring for her just as they do for the ICU’s 19 other patients. But prominent in the woman’s medical record were the words “NO CODE BLUE,” followed by a doctor’s jottings: “Spoke with family regarding patient’s extremely poor condition and prognosis. Family requests no code. Will comply with same.”

The patient, it turned out, had less than 24 hours to live. She went into cardiac arrest the following day and hospital personnel honored those specific orders written in her medical chart.

They are orders that are becoming increasingly common, even dominant, among terminal patients, experts say.

Simply Saying ‘No’

And to a growing number of medical ethics experts, they are proof of a tidal change in how Americans over the last decade have come to grips with the question of death: In increasing numbers, they--or their families when they are incapable of making such choices for themselves--are simply saying “no” to the use of exotic technology and heroic hospital rescue procedures.

The mechanism by which this is being done is most commonly called a “do not resuscitate” order, or DNR. In hospital shorthand parlance, it is referred to as a no-code, meaning that cardiac resuscitation and other massive interventions to prolong life are not to be undertaken.

While there is no comprehensive national statistical profile of DNRs, doctors at a hospital in New Britain, Conn., reported for the first time last month that almost two-thirds of ICU patients who die do so with DNR orders in effect. In a report published in the prominent journal Archives of Internal Medicine, the researchers found that in 1986, DNRs were in effect for 64% of those ICU patients who died, while four years earlier, DNRs were in effect for only 27% of similar patients who died.

“This study,” the researchers concluded, “finds that DNR orders have become the rule . . . rather than the exception.”

Biomedical ethics experts at Huntington and Cedars-Sinai Medical Center in Los Angeles, as well as Stanford University Hospital in Palo Alto, agree that DNRs now prevail among most groups of terminally ill patients.

“There is no question now that there is greatly increased acceptance of DNR orders,” said Dr. Michael Van Scoy-Mosher, a tumor treatment specialist who heads the Cedars-Sinai bioethics committee. “It has become a very accepted and commonplace thing.”

‘It Is Very Appropriate’

“It certainly seems to bear up all across the country,” said Dr. William Bartholome, an ethics expert at Kansas University Medical Center in Kansas City, Kan. “I think people are finally coming to the realization that it is very appropriate.”

Supporting the contention that the question is one rapidly coming to preoccupy many aspects of the health-care system, the California Emergency Medical Services Authority says it will soon introduce proposed statewide guidelines on how paramedics can legally honor DNRs. Already, the paramedic system in Santa Cruz County has a prototype DNR system in which paramedics can verify the existence of such an order through a central hospital file.

And the Chicago-based Joint Commission on Accreditation of Healthcare Organizations has required, since early this year, that hospitals have written policies on how they deal with DNR requests by patients.

DNRs are intended to give people a choice. They are a specific part of a larger continuum of measures by which a person can control his or her health care but they pertain usually to the specific act of emergency resuscitation and do not directly pertain to questions of providing food and fluid and other ethical issues.

New Technology

Their popularity or acceptance has come almost directly from the development over the last 15 years of new technology that can sustain life or even return to life patients who would once have been termed clinically dead.

Alexander Capron, former executive director of the President’s Commission for the Study of Ethical Problems in Medicine and now a USC law and ethics professor, pointed out that the process of resuscitation can often bring back to “life” a patient who then survives in a coma or in great pain for a few more days, weeks or months.

Studies of the eventual outcomes of patients resuscitated in hospitals have consistently found only a 5% to 20% success rate when the outcome is measured in terms of whether the patient was eventually discharged in reasonably good health. In 1983, for instance, researchers at Beth Israel Hospital in Boston found that of 294 patients resuscitated in a major teaching hospital, only 14% survived to be discharged and a quarter of those died within six months.

There has also been concern about pain and suffering caused by resuscitation itself. Successful CPR, even when performed on resilient younger people, usually results in injuries such as broken ribs. It can be extremely traumatic in older, ill victims.

“The whole process of resuscitation is a very brutal one,” Stanford University’s Dr. John Ruark said, “and, certainly in the case of the debilitated older person, it’s difficult to make a case that it should be undertaken at all.”

“The question is: Where do you stop? I think we all know that you’re not always doing people a service by resuscitating them,” said Dr. Palmi Jonsson, the doctor who headed the Connecticut study.

There is also the question of cost. Capron said that physicians trained in the last 10 years have been taught to take into account the financial ramifications and cost-benefit equations of treatments they recommend.

“We can’t avoid the fact that society has created in the minds ofall of us concerns not only about bodily integrity and personal well-being and autonomy but about respect for economics,” Capron said.

“It’s possible to keep the heart and the lungs going for a very long time,” said Dr. William Manson, chairman of the Huntington bioethics committee. “When you get to those levels of expense, it comes out of the world’s total resources. It doesn’t matter who pays for it. It’s wasteful.”

But to many observers, the increasing popularity of do-not-resuscitate orders poses a major challenge to physicians and the health-care community. Most experts questioned by The Times agreed that the increased use of DNRs has developed at the grass-roots level among health care consumers.

The newly published study found almost two-thirds of the DNRs were written only within the last three days of the patient’s life. “What that indicates is that the issue arose too late,” Capron said. “I suspect it reflects the fact that, although DNR orders are no longer secret, there still isn’t comfort in the medical community with making this a standard topic of conversation.” He said it is his impression that only 20% of adults who are hospitalized in the United States have ever discussed DNRs with their physicians.

Advance Planning

Specifically, the experts suggest that:

--All adults should decide what they would specifically want done in the event they suffer a catastrophic medical event, and they should discuss such wishes in detail with their families and with their physicians.

--In California and most other states, a document called a “durable power of attorney” can be used to specify someone who is empowered to make choices for you on questions that include the issue of resuscitation if you are unable to do so. In New York State, a first-in-the-nation law that took effect in April guarantees adults the right to have their wishes not to be resuscitated honored.

--But even with such a document, you should make sure both family members and physicians who may be involved in your treatment understand precisely what heroic measures are wanted. Someone with a heart condition, for instance, may wish to have CPR performed if it can be initiated quickly enough to avoid brain damage but may not want anything to be done should there be a delay.

Along with the increased use of DNRs has come, on the other hand, an equally growing concern about the potential for abuse, including the predictable fears of a trend toward euthanasia.

Ruark participated in a landmark Stanford study by the university hospital’s committee on ethics that called earlier this year for a more open-minded approach to such issues in all hospitals. Although he called the trend toward more DNRs “laudable,” he advised caution.

“It’s a complicated trend,” he said. “DNRs can be written without regard for patient rights and one of the concerns we have is that, too often and particularly for elderly people who are mentally incompetent, DNRs may be written without any kind of due process.”

Indeed, the Connecticut study found that patient-originated DNRs were in effect in only 14% of the 244 cases reviewed even though there were DNRs in effect for almost two thirds of the ICU patients who died. Family members had been consulted in 77% of the cases; the records in the remaining cases were unclear.

If the question of making an informed decision not to resuscitate in a hospital is difficult enough, experts agree it is even harder to enforce such wishes out of health centers. In two metropolitan areas--Minneapolis-St. Paul in Minnesota and Kansas City, Mo., and Kansas City, Kan.--paramedic systems and other health providers have established working procedures in which a legally executed DNR can be honored by ambulance crews or rescue workers on their arrival at the home of a stricken victim.

The EMS authority’s Haynes said the proposed California guidelines, which will be subject to an extended public comment process, would be of use to terminal patients who are receiving hospice care in their homes but who wish to be allowed to die without medical intervention.

But they could be especially useful to nursing home patients who have DNRs on file but who require hospitalization as a result of a sudden health problem. Often, Haynes said, paramedics called by nursing home officials resuscitate such patients routinely.

“There has been enormous reluctance on the part of the emergency medical services community to deal with this issue,” Haynes said, “but . . . there is a growing realization that, in many situations, resuscitation is not what patients want.”

“That is the most macabre thing,” Capron agreed. “You have prepared to meet death in the nursing home. But suddenly, you’re being rushed out of the nursing home and shipped off in an ambulance only to have someone beat on your chest until you die. (It would be difficult) to think up a worse form of torture.”