'Doctor, Don't Give Up on Me!'

Leigh Page

Disclosures

March 16, 2016

In This Article

How DNRs Can Be Misused

What are we to make of Finlay's experiences with her mother's care? It might be argued that Canadian doctors, who have to deal with explicit rationing, are more eager than US doctors to withhold care. But, in fact, US doctors in some hospitals have very high DNR rates. In a US study[12] in 2014, doctors' use of DNR orders for stroke cases varied from 23.2% in the highest quintile of hospitals to 2.2% in the lowest quintile.

One reason for the wide variation in the use of DNRs is that doctors may not agree on what could happen to patients, according to Constantine A. Manthous, MD, an intensivist at Lawrence and Memorial Hospital in New London, Connecticut. Even in some of the finest ICUs in the country, "experienced medical professionals have not been able to reliably predict patient outcomes," he says.

US doctors frequently overrule patients' wishes on DNRs, just like the Canadian doctor did for Finlay's mother. In a survey[13] of the end-of-life care for patients aged 80 years and older, 9% of those who died without getting CPR did not have a DNR order in their chart, and almost 40% of those who died without CPR or those who had a written DNR order had a previously expressed desire for CPR.

Furthermore, some US doctors are also satisfied with the patient's nonverbal agreement to a DNR, according to Dr Manthous, who has studied intensivists' attitudes on withdrawing life-sustaining therapies. Some doctors, he says, are satisfied with a nonverbal "assent," which can mean simply not disagreeing with what the doctor says. Dr Manthous strongly opposes this approach. "Silence or lack of refusal does not mean acceptance," he says. The standard, he adds, should be the same as that for getting informed consent for surgery, which involves getting "a clear affirmation that the patient understands the consequences."

Sometimes, when doctors order DNRs without telling patients, they think the patient would get very upset over the mere mention of a DNR, Dr Manthous says. For this reason, he says, New York law[14] waives any requirement to get the patient's consent for a DNR if the doctor believes it would "harm" the patient. But Dr Manthous says that doctors' concerns here are overblown. In a 2006 study[15] he coauthored, 90% of patients said that they wanted to know about DNRs.

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