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Para el episodio de Los Soprano, vea No resucitar (Los Soprano) . Para el episodio de Batwoman, vea No resucitar (Batwoman) .
No resucitar
Virginia Sample DDNR.jpg
Formulario DNR utilizado en Virginia
Otros nombresNo intente reanimación, permita la muerte natural, sin código [ cita requerida ]

Una orden de no resucitar ( DNR ), también conocida como sin código [ cita requerida ] o permitir la muerte natural , es una orden legal, escrita u oral según el país, que indica que una persona no desea recibir resucitación cardiopulmonar (CPR ) si el corazón de esa persona deja de latir . [1] A veces también previene otras intervenciones médicas. [2] El estatus legal y los procesos que rodean las órdenes DNR varían de un país a otro. Por lo general, el pedido lo realiza un médico basándose en una combinación de juicio médico y deseos y valores del paciente. [3]

Base para la elección [ editar ]

Las entrevistas con 26 pacientes DNR y 16 pacientes con código completo en Toronto en 2006-9 sugieren que la decisión de elegir el estado de no reanimar se basó en factores personales, incluida la salud y el estilo de vida; factores relacionales (con la familia o con la sociedad en su conjunto); y factores filosóficos. [4] Las grabaciones de audio de 19 discusiones sobre el estatus DNR entre médicos y pacientes en 2 hospitales de EE. UU. (San Francisco y Durham) en 2008-9 encontraron que los pacientes "mencionaron los riesgos, beneficios y resultados de la RCP" y los médicos "exploraron las preferencias uso a corto frente a largo plazo de la terapia de soporte vital ". [5]

Supervivencia de la RCP entre varios grupos

Resultados de la RCP [ editar ]

Artículo principal: Reanimación cardiopulmonar § Diferencias de supervivencia, según enfermedad previa, edad o ubicación

Cuando las instituciones médicas explican la DNR, describen la supervivencia de la RCP, con el fin de abordar las preocupaciones de los pacientes sobre los resultados. Después de la RCP en los hospitales en 2017, 7.000 pacientes sobrevivieron para salir vivos del hospital, de 26.000 intentos de RCP, o el 26%. [6] Después de la RCP fuera de los hospitales en 2018, 8.000 pacientes sobrevivieron para salir del hospital con vida, de 80.000 intentos de RCP, o el 10%. El éxito fue del 21% en un entorno público, donde era más probable que alguien viera a la persona colapsar y brindar ayuda que en un hogar. [7] El éxito fue del 35% cuando los transeúntes utilizaron un desfibrilador externo automático (DEA), fuera de los centros de salud y los hogares de ancianos. [7]

En la información sobre DNR, las instituciones médicas comparan la supervivencia de pacientes con múltiples enfermedades crónicas; [8] [9] pacientes con enfermedad cardíaca, pulmonar o renal; [8] [9] enfermedad del hígado; [8] cáncer generalizado [8] [9] [10] o infección; [10] y residentes de hogares de ancianos. [8] La investigación muestra que la supervivencia de la RCP es la misma que la tasa de supervivencia promedio de la RCP, o casi, para pacientes con múltiples enfermedades crónicas, [11] [12] o diabetes, enfermedades cardíacas o pulmonares. [13] La supervivencia es aproximadamente la mitad de buena que la tasa promedio, para pacientes con enfermedad renal o hepática, [13]o cáncer diseminado [13] [14] o infección. [13]

Para las personas que viven en hogares de ancianos, la supervivencia después de la RCP es aproximadamente de la mitad a las tres cuartas partes de la tasa promedio. [7] [11] [13] [15] [16] En los centros de salud y los hogares de ancianos donde los DEA están disponibles y se utilizan, las tasas de supervivencia son dos veces más altas que la supervivencia promedio encontrada en los hogares de ancianos en general. [7] Pocos hogares de ancianos tienen DEA. [17]

La investigación en 26,000 pacientes encontró similitudes en las situaciones de salud de los pacientes con y sin DNR. Para cada uno de los 10 niveles de enfermedad, desde el más saludable al más enfermo, del 7% al 36% de los pacientes tenían órdenes de DNR; el resto tenía código completo. [18]

Riesgos [ editar ]

Artículo principal: Reanimación cardiopulmonar § Consecuencias

Como se señaló anteriormente, los pacientes que están considerando DNR mencionan los riesgos de la RCP. Las lesiones físicas, como huesos rotos, afectan al 13% de los pacientes con RCP, [19] y un número adicional desconocido tiene cartílago roto que puede sonar como huesos rotos. [20] [21]

Los problemas mentales afectan a algunos pacientes, tanto antes como después de la RCP. Después de la RCP, hasta 1 persona más, de cada 100 supervivientes, está en coma que antes de la RCP (y la mayoría de las personas salen del coma [22] [23] ). De 5 a 10 personas más, de cada 100 sobrevivientes, necesitan más ayuda con la vida diaria que antes de la RCP. De 5 a 21 personas más, de cada 100 sobrevivientes, declinan mentalmente, pero se mantienen independientes. [24]

Donación de órganos [ editar ]

La donación de órganos es posible después de la RCP, pero generalmente no después de una muerte con DNR. Si la RCP no revive al paciente y continúa hasta que haya un quirófano disponible, se puede considerar la donación de riñones e hígado. Las pautas de EE. UU. Respaldan la donación de órganos, "Los pacientes que no tienen ROSC [retorno de la circulación espontánea] después de los esfuerzos de reanimación y que de otra manera tendrían fin de los esfuerzos pueden considerarse candidatos para la donación de riñón o hígado en entornos donde existen programas". [25] Las directrices europeas fomentan la donación, "Después de detener la RCP, se debe considerar la posibilidad de un apoyo continuo de la circulación y el transporte a un centro dedicado en perspectiva de la donación de órganos". [26] La RCP revive al 64% de los pacientes en los hospitales [27]y 43% fuera [7] (ROSC), lo que brinda a las familias la oportunidad de despedirse, [28] y todos los órganos pueden considerarse para la donación, "Recomendamos que todos los pacientes que son reanimados de un paro cardíaco pero que posteriormente progresan a la muerte o muerte cerebral sea evaluada para la donación de órganos ". [25]

En los EE. UU., Se trasplantan 1,000 órganos por año de pacientes que recibieron RCP. [29] Se pueden tomar donaciones del 40% de los pacientes que tienen ROSC y luego sufren muerte cerebral, [30] y se extrae un promedio de 3 órganos de cada paciente que dona órganos. [29] DNR generalmente no permite la donación de órganos.

Menos atención para los pacientes DNR [ editar ]

No se supone que las reducciones en otros cuidados sean el resultado de DNR, [1] pero lo hacen. Algunos pacientes eligen DNR porque prefieren menos atención: la mitad de los pacientes de Oregon con órdenes de DNR que completaron un POLST {conocido como POST (Órdenes del médico y alcance del tratamiento) en Tennessee} solo querían atención de confort y el 7% quería atención completa. El resto quería varios límites en la atención, por lo que las suposiciones generales no son confiables. [31] Hay muchos médicos que "malinterpretan las preferencias de DNR y, por lo tanto, no brindan otras intervenciones terapéuticas adecuadas". [18]

Los pacientes con DNR tienen menos probabilidades de recibir atención médica adecuada para una amplia gama de problemas, como transfusiones de sangre, cateterismos cardíacos, derivación cardíaca, operaciones para complicaciones quirúrgicas, [32] hemocultivos, colocación de vías centrales, [33] antibióticos y pruebas de diagnóstico. . [34] "[P] roveedores aplican intencionalmente las órdenes DNR de manera amplia porque asumen que los pacientes con órdenes DNR también preferirían abstenerse de otros tratamientos de soporte vital o creen que otros tratamientos no serían médicamente beneficiosos". [34] El 60% de los cirujanos no ofrecen operaciones con una mortalidad superior al 1% a los pacientes con DNR. [35]El hecho de no ofrecer una atención adecuada a los pacientes con DNR llevó al desarrollo de planes de atención y tratamiento de emergencia (ECTP), como el Plan Resumen Recomendado para la Atención y el Tratamiento de Emergencia (ReSPECT), que tiene como objetivo registrar recomendaciones sobre DNR junto con recomendaciones para otros tratamientos en una situación de emergencia. [36] Las ECTP han llevado a los médicos a contextualizar la RCP dentro de una consideración más amplia de las opciones de tratamiento, sin embargo, las ECTP se completan con mayor frecuencia para pacientes con riesgo de deterioro repentino y el enfoque tiende a estar en DNR. [37]

Por lo tanto, los pacientes con DNR mueren antes, incluso por causas no relacionadas con la RCP. Un estudio agrupó a 26.300 pacientes hospitalarios muy enfermos en 2006-10, desde los más enfermos hasta los más sanos, utilizando una escala detallada de 0 a 44. Compararon la supervivencia de pacientes del mismo nivel, con y sin órdenes de DNR. En el grupo más saludable, el 69% de aquellos sin DNR sobrevivieron para salir del hospital, mientras que solo el 7% de los pacientes igualmente sanos con DNR sobrevivieron. En el siguiente grupo más saludable, el 53% de los que no tenían DNR sobrevivieron y el 6% de los que tenían DNR. Entre los pacientes más enfermos, sobrevivió el 6% de aquellos sin DNR y ninguno con DNR. [18]

Dos médicos de Dartmouth señalan que "En la década de 1990 ... la 'reanimación' comenzó a aparecer cada vez más en la literatura médica para describir estrategias para tratar a personas con afecciones reversibles, como líquidos intravenosos para el shock por sangrado o infección ... el significado de DNR se volvió cada vez más confuso para los proveedores de atención médica ". [38] Otros investigadores confirman este patrón, utilizando "esfuerzos de reanimación" para cubrir una variedad de cuidados, desde el tratamiento de una reacción alérgica hasta la cirugía por una fractura de cadera. [39] Los médicos del hospital no se ponen de acuerdo sobre qué tratamientos negar a los pacientes DNR y documentan las decisiones en la tabla solo la mitad del tiempo. [33] Una encuesta con varios escenarios encontró médicos "Estuvo de acuerdo o totalmente de acuerdo en iniciar menos intervenciones cuando hubiera una orden de DNR.[33]

After successful CPR, hospitals often discuss putting the patient on DNR, to avoid another resuscitation. Guidelines generally call for a 72-hour wait to see what the prognosis is,[40] but within 12 hours US hospitals put up to 58% of survivors on DNR, and at the median hospital 23% received DNR orders at this early stage, much earlier than the guideline. The hospitals putting fewest patients on DNR had more successful survival rates, which the researchers suggest shows their better care in general.[18] When CPR happened outside the hospital, hospitals put up to 80% of survivors on DNR within 24 hours, with an average of 32.5%. The patients who received DNR orders had less treatment, and almost all died in the hospital. The researchers say families need to expect death if they agree to DNR in the hospital.[2]

Patients' values[edit]

The philosophical factors and preferences mentioned by patients and doctors are treated in the medical literature as strong guidelines for care, including DNR or CPR. "Complex medical aspects of a patient with a critical illness must be integrated with considerations of the patient’s values and preferences"[41] and "the preeminent place of patient values in determining the benefit or burden imposed by medical interventions."[42] Patients' most common goals include talking, touch, prayer, helping others, addressing fears, laughing.[43][44] Being mentally aware was as important to patients as avoiding pain, and doctors underestimated its importance and overestimated the importance of pain.[43] Dying at home was less important to most patients.[43] Three quarters of patients prefer longer survival over better health.[45]

Advance directive, living will, POLST, medical jewelry, tattoos[edit]

Advance directives and living wills are documents written by individuals themselves, so as to state their wishes for care, if they are no longer able to speak for themselves. In contrast, it is a physician or hospital staff member who writes a DNR "physician's order," based upon the wishes previously expressed by the individual in his or her advance directive or living will. Similarly, at a time when the individual is unable to express his wishes, but has previously used an advance directive to appoint an agent, then a physician can write such a DNR "physician's order" at the request of that individual's agent. These various situations are clearly enumerated in the "sample" DNR order presented on this page.

It should be stressed that, in the United States, an advance directive or living will is not sufficient to ensure a patient is treated under the DNR protocol, even if it is their wish, as neither an advance directive nor a living will legally binds doctors.[46] They can be legally binding in appointing a medical representative, but not in treatment decisions.

Physician Orders for Life-Sustaining Treatment (POLST) documents are the usual place where a DNR is recorded outside hospitals. A disability rights group criticizes the process, saying doctors are trained to offer very limited scenarios with no alternative treatments, and steer patients toward DNR. They also criticize that DNR orders are absolute, without variations for context.[47] The Mayo Clinic found in 2013 that "Most patients with DNR/DNI [do not intubate] orders want CPR and/or intubation in hypothetical clinical scenarios," so the patients had not had enough explanation of the DNR/DNI or did not understand the explanation.[48]

In the UK, emergency care and treatment plans (e.g. ReSPECT) are clinical recommendations written by healthcare professionals after discussion with patients or their relatives about their priorities of care.[49] Research has found that the involvement of patients or their family in forming ECTP recommendations is variable.[50] In some situations (where there are limited treatment options available, or where the patient is likely to deteriorate quickly) healthcare professionals will not explore the patient’s preferences, but will instead ensure that patients or their relatives understand what treatment will or will not be offered.[50]

Medical jewelry[edit]

Medical bracelets, medallions, and wallet cards from approved providers allow for identification of DNR patients outside in home or non-hospital settings. Each state has its own DNR policies, procedures, and accompanying paperwork for emergency medical service personnel to comply with such forms of DNR.[51]

DNR tattoos[edit]

There is a growing trend of using DNR tattoos, commonly placed on the chest, to replace other forms of DNR, but these often cause confusion and ethical dilemmas among healthcare providers.[52] Laws vary from state to state regarding what constitutes a valid DNR and currently do not include tattoos.[51] End of life (EOL) care preferences are dynamic and depend on factors such as health status, age, prognosis, healthcare access, and medical advancements. DNR orders can be rescinded while tattoos are far more difficult to remove. At least one person decided to get a DNR tattoo based on a dare while under the influence of alcohol.[53]

Ethics[edit]

DNR orders in certain situations have been subject to ethical debate. In many institutions it is customary for a patient going to surgery to have their DNR automatically rescinded. Though the rationale for this may be valid, as outcomes from CPR in the operating room are substantially better than general survival outcomes after CPR, the impact on patient autonomy has been debated. It is suggested that facilities engage patients or their decision makers in a 'reconsideration of DNR orders' instead of automatically making a forced decision.[54]

When a patient or family and doctors do not agree on a DNR status, it is common to ask the hospital ethics committee for help, but authors have pointed out that many members have little or no ethics training, some have little medical training, and they do have conflicts of interest by having the same employer and budget as the doctors.[55][56][57]

There is accumulating evidence of racial differences in rates of DNR adoption. A 2014 study of end stage cancer patients found that non-Latino white patients were significantly more likely to have a DNR order (45%) than black (25%) and Latino (20%) patients. The correlation between preferences against life-prolonging care and the increased likelihood of advance care planning is consistent across ethnic groups.[58]

Ethical dilemmas occur when a patient with a DNR attempts suicide and the necessary treatment involves ventilation or CPR. In these cases it has been argued that the principle of beneficence takes precedence over patient autonomy and the DNR can be revoked by the physician.[59] Another dilemma occurs when a medical error happens to a patient with a DNR. If the error is reversible only with CPR or ventilation there is no consensus if resuscitation should take place or not.[60]

There are also ethical concerns around how patients reach the decision to agree to a DNR order. One study found that patients wanted intubation in several scenarios, even when they had a Do Not Intubate (DNI) order, which raises a question whether patients with DNR orders may want CPR in some scenarios too.[61][48][62] It is possible that providers are having a "leading conversation" with patients or mistakenly leaving crucial information out when discussing DNR.[61][47]

One study reported that while 88% of young doctor trainees at two hospitals in California in 2013 believed they themselves would ask for a DNR order if they were terminally ill, they are flexible enough to give high intensity care to patients who have not chosen DNR.[63][64]

There is also the ethical issue of discontinuation of an implantable cardioverter defibrillator (ICD) in DNR patients in cases of medical futility. A large survey of Electrophysiology practitioners, the heart specialists who implant pacemakers and ICDs, noted that the practitioners felt that deactivating an ICD was not ethically distinct from withholding CPR thus consistent with DNR. Most felt that deactivating a pacemaker was a separate issue and could not be broadly ethically endorsed. Pacemakers were felt to be unique devices, or ethically taking a role of "keeping a patient alive" like dialysis.[65]

Terminology[edit]

DNR and Do Not Resuscitate are common terms in the United States, Canada, New Zealand and the United Kingdom. This may be expanded in some regions with the addition of DNI (Do Not Intubate). In some hospitals DNR alone will imply no intubation,[66] though 98% of intubations are unrelated to cardiac arrest; most intubations are for pneumonia or surgery.[67] Clinically, the vast majority of people requiring resuscitation will require intubation, making a DNI alone problematic. Hospitals sometimes use the expression no code,[citation needed] which refers to the jargon term code, short for Code Blue, an alert to a hospital's resuscitation team.

Some areas of the United States and the United Kingdom include the letter A, as in DNAR, to clarify "Do Not Attempt Resuscitation". This alteration is so that it is not presumed by the patient or family that an attempt at resuscitation will be successful.

As noted above in Less care for DNR patients, the word "resuscitation" has grown to include many treatments other than CPR, so DNR has become ambiguous, and authors recommend "No CPR" instead.[38]

Since the term DNR implies the omission of action, and therefore "giving up", a few authors have advocated for these orders to be retermed Allow Natural Death.[68][69] Others say AND is ambiguous whether it would allow morphine, antibiotics, hydration or other treatments as part of a natural death.[70][71]New Zealand and Australia, and some hospitals in the UK, use the term NFR or Not For Resuscitation. Typically these abbreviations are not punctuated, e.g., DNR rather than D.N.R.

Resuscitation orders, or lack thereof, can also be referred to in the United States as a part of Physician Orders for Life-Sustaining Treatment (POLST), Medical Orders for Life-Sustaining Treatment (MOLST), Physician's Orders on Scope of Treatment (POST) or Transportable Physician Orders for Patient Preferences (TPOPP) orders,[72] typically created with input from next of kin when the patient or client is not able to communicate their wishes.

Another synonymous term is "not to be resuscitated" (NTBR).[73]

Until recently in the UK it was common to write "Not for 222" or conversationally, "Not for twos". This was implicitly a hospital DNR order, where 222 (or similar) is the hospital telephone number for the emergency resuscitation or crash team.[citation needed] Current UK practice is for resuscitation recommendations to be standalone orders (such as DNACPR) or embedded within broader emergency care and treatment plans (ECTPs), such as the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT).[49]

Usage by country[edit]

DNR documents are widespread in some countries and unavailable in others. In countries where a DNR is unavailable the decision to end resuscitation is made solely by physicians.

A 2016 paper reports a survey of small numbers of doctors in numerous countries, asking "how often do you discuss decisions about resuscitation with patients and/or their family?" and "How do you communicate these decisions to other doctors in your institution?"[74] Some countries had multiple respondents, who did not always act the same, as shown below. There was also a question "Does national guidance exist for making resuscitation decisions in your country?" but the concept of "guidance" had no consistent definition, For example, in the US, four respondents said yes, and two said no.

Doctors' approaches to communication about resuscitation[74]
CountryDiscuss with patient or familyTell other doctors the decision
ArgentinaRarelyOral
AustraliaMost, halfOral+notes+pre-printed,(2) notes
AustriaHalfNotes
BarbadosHalfOral+notes
BelgiumHalf, rarelyNotes+electronic
BrazilMostOral+notes
BruneiRarelyOral+notes
CanadaAlways, mostOral+notes, oral+notes+electronic, notes+pre-printed
ColombiaHalfOral
CubaAlwaysOral
DenmarkMostElectronic
FranceMostPre-printed,
GermanyAlwaysOral+notes+electronic
Hong KongAlways, halfNotes+pre-printed, oral+notes+pre-printed
HungaryRarelyOral
IcelandRarelyNotes+electronic
IndiaAlwaysNotes, oral, oral+notes
IrelandMost, rarelyNotes (2)
IsraelMost, halfOral+notes,(2) notes
JapanMost, halfOral, notes
LebanonMostOral+notes+electronic
MalaysiaRarelyNotes
MaltaMostNotes
New ZealandAlwaysPre-printed
NetherlandsHalfElectronic (3)
NorwayAlways, rarelyOral, notes+electronic
PakistanAlwaysNotes+electronic
PolandAlways, mostOral+notes, notes+pre-printed
Puerto RicoAlwaysPre-printed
Saudi ArabiaAlways, mostPre-printed, notes+electronic, oral
SingaporeAlways, most, halfPre-printed (2), oral+notes+pre-printed, oral+notes+electronic, oral+pre-printed
South AfricaRarelyOral+notes
South KoreaAlwaysPre-printed
SpainAlways, mostPre-printed, oral+notes+electronic, oral+notes+pre-printed
Sri LankaMostNotes
SwedenMostOral+notes+pre-printed+electronic
SwitzerlandMost, halfOral+notes+pre-printed, oral+notes+other
TaiwanHalf, rarelyNotes+pre-printed+other, oral
UAEHalfOral+notes
UgandaAlwaysNotes,
USAAlways, mostNotes, electronic, oral+electronic, oral+notes+electronic, oral+notes+pre-printed+electronic

Middle East[edit]

DNRs are not recognized by Jordan. Physicians attempt to resuscitate all patients regardless of individual or familial wishes.[75] The UAE have laws forcing healthcare staff to resuscitate a patient even if the patient has a DNR or does not wish to live. There are penalties for breaching the laws.[76] In Saudi Arabia patients cannot legally sign a DNR, but a DNR can be accepted by order of the primary physician in case of terminally ill patients. In Israel, it is possible to sign a DNR form as long as the patient is dying and aware of their actions.[citation needed]

United Kingdom[edit]

DNACPR form as used in Scotland

England and Wales[edit]

In England and Wales, CPR is presumed in the event of a cardiac arrest unless a do not resuscitate order is in place. If they have capacity as defined under the Mental Capacity Act 2005 the patient may decline resuscitation. Patients may also specify their wishes and/or devolve their decision-making to a proxy using an advance directive, which are commonly referred to as 'Living Wills', or an emergency care and treatment plan (ECTP), such as ReSPECT. Discussion between patient and doctor is integral to decisions made in advance directives and ECTPs, where resuscitation recommendations should be made within a more holistic consideration of all treatment options.[49] Patients and relatives cannot demand treatment (including CPR) which the doctor believes is futile and in this situation, it is their doctor's duty to act in their 'best interest', whether that means continuing or discontinuing treatment, using their clinical judgment. If the patient lacks capacity, relatives will often be asked for their opinion out of respect. Evaluation of ReSPECT (an ECTP) found that resuscitation status remained a central component of conversations, and that there was variability in the discussion of other emergency treatments.[37]

In 2020 the Care Quality Commission found that residents of care homes had been given inappropriate orders of Do not attempt cardiopulmonary resuscitation (DNACPR) without notice to residents or their families, causing avoidable deaths.[77] In 2021 the Mencap charity found that people with learning disabilities also had inappropriate DNACPR orders.[78] Medical providers have said that any discussion with patients and families is not in reference to consent to resuscitation and instead should be an explanation.[79]

Scotland[edit]

In Scotland, the terminology used is "Do Not Attempt Cardiopulmonary Resuscitation" or "DNACPR". There is a single policy used across all of NHS Scotland. The legal standing is similar to that in England and Wales, in that CPR is viewed as a treatment and, although there is a general presumption that CPR will be performed in the case of cardiac arrest, this is not the case if it is viewed by the treating clinician to be futile. Patients and families cannot demand CPR to be performed if it is felt to be futile (as with any medical treatment) and a DNACPR can be issued despite disagreement, although it is good practice to involve all parties in the discussion.[80]

United States[edit]

In the United States the documentation is especially complicated in that each state accepts different forms, and advance directives and living wills may not be accepted by EMS as legally valid forms. If a patient has a living will that specifies the patient requests DNR but does not have a properly filled out state-sponsored form that is co-signed by a physician, EMS may attempt resuscitation.

The DNR decision by patients was first litigated in 1976 in In re Quinlan. The New Jersey Supreme Court upheld the right of Karen Ann Quinlan's parents to order her removal from artificial ventilation. In 1991 Congress passed into law the Patient Self-Determination Act that mandated hospitals honor an person's decision in their healthcare.[81] Forty-nine states currently permit the next of kin to make medical decisions of incapacitated relatives, the exception being Missouri. Missouri has a Living Will Statute that requires two witnesses to any signed advance directive that results in a DNR/DNI code status in the hospital.

In the United States, cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) will not be performed if a valid written DNR order is present. Many states do not recognize living wills or health care proxies in the prehospital setting and prehospital personnel in those areas may be required to initiate resuscitation measures unless a specific state-sponsored form is properly filled out and cosigned by a physician.[82][83]

Canada[edit]

Do not resuscitate orders are similar to those used in the United States. In 1995, the Canadian Medical Association, Canadian Hospital Association, Canadian Nursing Association, and Catholic Health Association of Canada worked with the Canadian Bar Association to clarify and create a Joint Statement on Resuscitative Interventions guideline for use to determine when and how DNR orders are assigned.[84] DNR orders must be discussed by doctors with the patient or patient agents or patient's significant others. Unilateral DNR by medical professionals can only be used if the patient is in a vegetative state.[84]

Australia[edit]

In Australia, Do Not Resuscitate orders are covered by legislation on a state-by-state basis.

In Victoria, a Refusal of Medical Treatment certificate is a legal means to refuse medical treatments of current medical conditions. It does not apply to palliative care (reasonable pain relief; food and drink). An Advanced Care Directive legally defines the medical treatments that a person may choose to receive (or not to receive) in various defined circumstances. It can be used to refuse resuscitation, so as avoid needless suffering.[85]

In NSW, a Resuscitation Plan is a medically authorised order to use or withhold resuscitation measures, and which documents other aspects of treatment relevant at end of life. Such plans are only valid for patients of a doctor who is a NSW Health staff member. The plan allows for the refusal of any and all life-sustaining treatments, the advance refusal for a time of future incapacity, and the decision to move to purely palliative care.[86]

Italy[edit]

In Italy DNR is included in the italian law no. 219 of December 22th 2017 "Disposizioni Anticipate di Trattamento" or DAT, also called "biotestamento". The law no.219 "Rules on informed consent and advance treatment provisions", reaffirm the freedom of choice of the individual and make concrete the right to health protection, respecting the dignity of the person and the quality of life. The DAT are the provisions that every person of age and capable of understanding and wanting can express regarding the acceptance or rejection of certain diagnostic tests or therapeutic choices and individual health treatments, in anticipation of a possible future inability to self-determine. To be valid, the DATs must have been drawn up only after the person has acquired adequate medical information on the consequences of the choices he intends to make through the DAT. With the entry into force of law 219/2017, every person of age and capable of understanding and willing can draw up his DAT. Furthermore, the DATs must be drawn up with: public act authenticated private writing simple private deed delivered personally to the registry office of the municipality of residence or to the health structures of the regions that have regulated the DAT Due to particular physical conditions of disability, the DAT can be expressed through video recording or with devices that allow the person with disabilities to communicate. The DATs do not expire. They can be renewed, modified or revoked at any time, with the same forms in which they can be drawn up. With the DAT it is also possible to appoint a trustee, as long as he is of age and capable of understanding and willing, who is called to represent the signatory of the DAT who has become incapable in relations with the doctor and health facilities. With the Decree of 22 March 2018, the Ministry of Health established a national database for the registration of advance treatment provisions. Without the expression of any preference by the patient, Physicians must attempt to resuscitate all patients regardless of familial wishes.[87]

Taiwan[edit]

In Taiwan, patients sign their own DNR orders, and are required to do so to receive hospice care.[88] However, one study looking at insights into Chinese perspectives on DNR showed that the majority of DNR orders in Taiwan were signed by surrogates.[89] Typically doctors discuss the issue of DNR with the patients family rather than the patient themselves.[90] In Taiwan, there are two separate types of DNR forms: DNR-P which the patient themselves sign and DNR-S in which a designated surrogate can sign. Typically, the time period between signing the DNR and death is very short, showing that signing a DNR in Taiwan is typically delayed. Two witnesses must also be present in order for a DNR to be signed.[90]

DNR orders have been legal in Taiwan since May 2000 and were enacted by the Hospice and Palliative Regulation. Also included in the Hospice and Palliative Regulation is the requirement to inform a patient of their terminal condition, however, the requirement is not explicitly defined leading to interpretation of exact truth telling.[90]

Japan[edit]

In Japan, DNR orders are known as Do Not Attempt Resuscitation (DNAR). Currently, there are no laws or guidelines in place regarding DNAR orders but they are still routinely used.[91] A request to withdraw from life support can be completed by the patient or a surrogate.[92] In addition, it is common for Japanese doctors and nurses to be involved in the decision making process for the DNAR form.[93]

France[edit]

In 2005, France implemented its "Patients' Rights and End of Life Care" act. This act allows the withholding/withdrawal of life support treatment and as well as the intensified usage of certain medications that can quicken the action of death. This act also specifies the requirements of the act.[94]

The "Patients' Rights and End of Life Care" Act includes three main measures. First, it prohibits the continuation of futile medical treatments. Secondly, it empowers the right to palliative care that may also include the intensification of the doses of certain medications that can result in the shortening the patient's life span. Lastly, it strengthens the principle of patient autonomy. If the patient is unable to make a decision, the discussion, thus, goes to a trusted third party.[95]

See also[edit]

 Medicine portal

References[edit]

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  61. ^ a b Capone's paper, and the original by Jesus et al. say the patients were asked about CPR, but the questionnaire shows they were only asked whether they wanted intubation in various scenarios. This is an example of doctors using the term resuscitation to cover other treatments than CPR. Capone RA (March 2014). "Problems with DNR and DNI orders". Ethics & Medics. 39 (3): 1–3.
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External links[edit]

  • "Do Not Resuscitate Orders". MedlinePlus. U.S. National Library of Medicine.
  • "Decisions Relating to Cardiopulmonary Resuscitation". Resuscitation Council (UK).
  • Resuscitation Council UK ReSPECT process