Unilateral Do-Not-Resuscitate Orders: Navigating Ethical Complexities and Clinical Realities

The practice of medicine, particularly in critical care settings, often involves complex ethical decisions that challenge clinicians, patients, and families alike. One such area of profound ethical and practical consideration is the implementation of unilateral Do-Not-Resuscitate (DNR) orders. These orders, where a physician decides not to perform cardiopulmonary resuscitation (CPR) without explicit patient or surrogate consent, are increasingly coming under scrutiny for their varied application, potential for bias, and implications for patient autonomy. A recent discussion on the GeriPal Podcast, featuring leading palliative care and critical care physicians, shed light on the nuanced landscape of unilateral DNRs, highlighting concerns about their definition, ethical justification, and documentation.

The conversation, hosted by Eric Widera and Alex Smith, brought together Dr. Gina Piscatello, an ethicist and researcher from the University of Pittsburgh, and Drs. Erin DeMartino and Will Parker, both ethicists and researchers from the Mayo Clinic and the University of Chicago, respectively. Their collective expertise provided a comprehensive overview of the challenges and considerations surrounding unilateral DNR orders, a practice that, while sometimes perceived as a necessary tool in futile medical situations, carries significant ethical weight.

Defining Unilateral DNR Orders: A Spectrum of Practice

At its core, a unilateral DNR order signifies a physician’s decision to forgo CPR, a decision that, in its strictest definition, does not require patient or surrogate consent to be enacted. Dr. Piscatello clarified that ideally, these decisions are made prior to a cardiac arrest, differentiating them from on-the-spot decisions made during a code. However, the reality of clinical practice, particularly in intensive care units, blurs these lines.

Dr. Will Parker pointed out that the very act of stopping CPR after a prolonged resuscitation attempt, often after 20 to 30 minutes, is a unilateral clinical decision. With advancements like extracorporeal membrane oxygenation (ECMO), clinicians are constantly making subjective judgments about the likelihood of success for resuscitation measures, inherently introducing a unilateral element. This inherent subjectivity raises questions about when and how these decisions are made, and whether they are always based on objective medical futility or influenced by other factors.

The "Assent" vs. "Conflict" Dichotomy

The discussion revealed a critical distinction within the concept of unilateral DNRs: assent and conflict models.

• Assent Unilateral DNR: This scenario, as described by Dr. Parker, involves a clinician informing the family that CPR will not be performed, explaining the medical reasoning, and the family assenting to this decision. While the family doesn’t dissent, they are not explicitly given the choice to proceed with CPR. This practice, Dr. Parker suggests, is likely pervasive and often undocumented as such in electronic health records.
• Conflict Unilateral DNR: This is the more commonly understood form, where a family explicitly rejects the clinician’s recommendation against CPR and insists on its administration. While a conflict DNR is a clear instance of unilateral decision-making by the physician, the assent model presents a more subtle ethical challenge.

Dr. Parker argued that assent unilateral DNRs are ethically equivalent in many respects to conflict unilateral DNRs, as they bypass a direct, affirmative consent from the patient or surrogate for the decision to forgo CPR. This raises concerns about patient autonomy, even when the physician believes they are acting in the patient’s best interest.

The Ethical Tightrope: Futility, Autonomy, and Bias

A central theme of the podcast was the definition and application of "medical futility." While CPR is undeniably futile when there is no physiological possibility of restoring spontaneous circulation, the line between medical futility and qualitative judgments about a patient’s quality of life can become blurred.

Dr. Erin DeMartino emphasized the need for strict discipline in the use of the word "futility," distinguishing between physiological futility and qualitative assessments. She questioned the physician’s role in making such profound judgments, especially when the probability of success, however slim, remains. The risk, as highlighted by Dr. Piscatello, is that unilateral DNRs may be implemented not solely based on medical futility, but also due to a physician’s moral distress or personal judgment that CPR is not appropriate for a particular patient, regardless of their potential for survival.

This concern is amplified by the documented disparities in the application of unilateral DNRs. Dr. Piscatello’s research during the COVID-19 pandemic revealed that Spanish-speaking patients were significantly more likely to have unilateral DNR orders placed compared to similarly ill patients. While language barriers and difficulties in reaching families were cited as potential reasons, the observation that non-Spanish speaking patients with similar prognoses did not receive such orders pointed to an unsettling possibility of implicit bias influencing these critical decisions.

Variation in State Laws and Institutional Policies

The fragmented legal landscape surrounding unilateral DNRs across the United States further complicates the issue. Dr. Piscatello’s study of state statutes found that 49 states permit clinicians to decline initiating or maintaining at least one form of life support, including dialysis, CPR, or ECMO. However, the justifications for these decisions and the oversight mechanisms vary dramatically. Some states require medical reasons, others conscience-based reasons, and the definitions of "medically inappropriate" or "standard of practice" are often vague and open to interpretation.

This variation creates a system where the availability and application of unilateral DNRs can depend heavily on geographic location and institutional policy. For instance, while some institutions have pathways for unilateral DNRs with ethical committee consultations, others, like the VA system mentioned by Dr. Widera, do not permit them. This inconsistency can lead to confusion for trainees and disparities in patient care.

Documentation and Transparency: A Call for Clarity

The lack of standardized and transparent documentation for unilateral DNRs is another significant concern. Dr. Piscatello argued that a simple DNR order in the electronic health record (EHR) does not adequately capture the nuances of how that decision was made. If a patient improves, it becomes difficult to ascertain whether the DNR was a true reflection of their values or a unilateral physician decision. This lack of clarity can hinder re-evaluation of the patient’s code status and potentially lead to unwanted interventions or the failure to reinstate CPR if the patient’s condition improves.

The proposal of a distinct "unilateral DNR order" within EHRs, as implemented in some institutions, could offer greater transparency. Such an order would necessitate documentation of the physician’s reasoning, the discussions held (or lack thereof), and confirmation that certain institutional requirements, such as informing the surrogate, have been met. This would not only aid in re-evaluation but also provide a crucial safeguard against the arbitrary or biased application of these orders.

The "Assent" Model: Bridging the Gap or Sidestepping Consent?

The discussion also delved into the nature of "assent" unilateral DNRs and their ethical standing. While some clinicians, like Dr. Parker, view them as a pragmatic approach to situations where direct confrontation might be detrimental, others express reservations. Dr. Alex Smith, speaking from a palliative care perspective, suggested that the palliative care approach of building rapport, understanding patient values, and making recommendations based on those values and prognosis offers a more ethically sound pathway than the "menu options" often presented.

The concern with the assent model is that it can inadvertently normalize unilateral decision-making. Even if a family agrees with the clinician’s assessment, the lack of explicit choice to proceed with CPR can still be seen as undermining patient autonomy, especially given the historical distrust some communities have towards the healthcare system, as noted by Dr. Will Parker.

Magic Wand Solutions: Prioritizing Clarity, Futility, and Transparency

When asked about their ideal interventions with a "magic wand," the experts offered compelling visions for improvement:

• Dr. Erin DeMartino would focus on ensuring strict and precise definitions of "futility," emphasizing physiological criteria over qualitative judgments. This would involve a more rigorous approach to determining when CPR is truly medically impossible, rather than subjective assessments of quality of life.
• Dr. Will Parker would advocate for mandatory, explicit documentation of the reasoning behind withholding any life-sustaining therapy. This would bring transparency to decisions that currently lack clear justification, akin to the detailed notes often required for surgical interventions.
• Dr. Gina Piscatello would prioritize supporting patients and families through these difficult decisions, emphasizing transparency and ensuring patients have robust advocacy rights. Her focus would be on ensuring that unilateral DNRs, when implemented, are handled with maximum ethical consideration and clear communication.

Conclusion: Towards a More Ethical and Transparent Future

The conversation on the GeriPal Podcast underscored that unilateral DNR orders, while perhaps sometimes employed with good intentions in complex clinical scenarios, represent a significant ethical frontier in healthcare. The varied definitions, inconsistent application, potential for bias, and documentation challenges all point to a need for greater clarity, standardization, and ethical rigor. As medicine continues to advance, so too must our commitment to ensuring that critical decisions about life and death are made with the utmost respect for patient autonomy, transparency, and a steadfast adherence to ethical principles. The ongoing dialogue and research in this area are crucial steps towards achieving a healthcare system that navigates these complex issues with greater wisdom and compassion.