Do not resuscitate (No Code)

Do not resuscitate

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Do not resuscitate
Virginia Sample DDNR.jpg

DNR form used in Virginia
Synonyms Do not attempt resuscitation, allow natural death, no code

Do Not Resuscitate (DNR), also known as no code or allow natural death, is a legal order, written or oral depending on country, to withhold cardiopulmonary resuscitation (CPR) or advanced cardiac life support (ACLS) in case their heart were to stop or they were to stop breathing. Many countries do not allow a DNR order. In most countries which do, the order is made by a doctor. In some countries this is based on the wishes of the patient or health care power of attorney.[1]

US research finds that 26% of patients who require CPR while in the hospital, and 16% of patients who require CPR outside the hospital, survive to be discharged from the hospital alive. Patients who are over 85, live in nursing homes, have multiple medical problems, or who have cancer, are slightly less likely to survive.

A DNR is not intended to affect any treatment other than CPR, but research shows that patients with DNR orders receive less care and die sooner than other patients with similar health.

Outcomes after CPR and DNR

There is little literature on why some patients choose DNR and others choose CPR. In the 1990s there was an expectation that old people would not survive CPR or would become mentally disabled.[2] [3]

Survival rates have risen substantially, even among the very old and sick, and are expected to rise further, as the best practices spread, and improvements are found.[4] [5]

In US hospitals in 2016, 26% of patients who received CPR survived to hospital discharge.[6] In 2017 in the US, outside hospitals, 16% of people whose cardiac arrest was witnessed survived to hospital discharge.[7]

Since 2003, widespread cooling of patients after CPR[8] and other improvements have raised survival and reduced mental disabilities.

89% of patients have the same mental abilities after CPR, based on before and after measurement of 12,500 US patients’ Cerebral-Performance Category (CPC[9]) codes in a 2000-2009 study of CPR in hospitals. 1% more survivors were in comas than before CPR. 5% more needed help with daily activities. 5% more had moderate mental problems and could still be independent.[10]

For CPR outside hospitals, a Copenhagen study of 2,504 patients in 2007-2011 found 21% of survivors developed moderate mental problems but could still be independent, and 11% of survivors developed severe mental problems, so they needed daily help. Two patients out of 2,504 went into comas (0.1% of patients, or 2 out of 419 aurvivors, 0.5%).[11]

Most people in comas start to get better in 2–3 weeks.[12] 2018 guidelines on disorders of consciousness say it is no longer appropriate to use the term “permanent vegetative state.”[13] Mental abilities can continue to improve in the six months after discharge,[14] and in subsequent years.[12] For long term problems, brains form new paths to replace damaged areas.[15][16]

87% of patients are not injured by CPR.[17] Broken ribs are present in 3% (2009-12 data)[17] to 8% (1997–99)[18] of those who survive to hospital discharge. In the 2009-12 study, 20% of survivors were older than 75.[17] Of those who died in the hospital, 15% had broken ribs (2009–12).[17] A study in the 1990s found 55% of CPR patients who died before discharge had broken ribs, and a study in the 1960s found 97% did; training and experience levels have improved.[19] Lung injuries were given to 3% of patients and other internal bleeding to 3% (2009-12). Most injuries did not affect care; only 1% of those given CPR received life-threatening injuries from it.[17]

A 2004 overview said, “Chest injury is a price worth paying to achieve optimal efficacy of chest compressions. Cautious or faint-hearted chest compression may save bones in the individual case but not the patient’s life.”[19] The costal cartilage also breaks in an unknown number of additional cases, which can sound like breaking bones.[20][21]

Organ donation is possible after CPR, but not usually after a death with a DNR. If CPR does not revive the patient, and continues until an operating room is available, kidneys and liver can be considered for donation. US Guidelines endorse organ donation, “Patients who do not have ROSC [return of spontaneous circulation] after resuscitation efforts and who would otherwise have termination of efforts may be considered candidates for kidney or liver donation in settings where programs exist.”[22]European guidelines encourage donation, “After stopping CPR, the possibility of ongoing support of the circulation and transport to a dedicated centre in perspective of organ donation should be considered.”[23] CPR revives 64% of patients in hospitals[24] and 43% outside[7] (ROSC), which gives families a chance to say goodbye,[25] and all organs can be considered for donation, “We recommend that all patients who are resuscitated from cardiac arrest but who subsequently progress to death or brain death be evaluated for organ donation.”[22]

1,000 organs per year in the US are transplanted from patients who had CPR.[26] Donations can be taken from 40% of patients who have ROSC and later become brain dead,[27] and an average of 3 organs are taken from each patient who donates organs.[26] DNR does not usually allow organ donation.

The American Heart Association guidelines say that survival rates below 1% are “futility,”[28] but all groups have much better survival than that. Even among very sick patients at least 10% survive: A study of CPR in a sample of US hospitals from 2001 to 2010,[29] where overall survival was 19%, found 10% survival among cancer patients, 12% among dialysis patients, 14% over age 80, 15% among blacks, 17% for patients who lived in nursing homes, 19% for patients with heart failure, and 25% for patients with heart monitoring outside the ICU, so there is room for good practices to spread, raising the averages. Another study, of advanced cancer patients, found the same 10% survival.[30]

An earlier study of Medicare patients in hospitals 1992-2005, where overall survival was 18%, found 13% survival in the poorest neighborhoods, 12% survival over age 90, 15% survival among ages 85–89, and 17% survival among ages 80–84.[31]

A study of King County WA patients who had CPR outside hospitals in 1999-2003, where 34% survived to hospital discharge overall, found that among patients with 4 or more major medical conditions, 18% survived; with 3 major conditions 24% survived, and 33% of those with 2 major medical conditions survived.[32]

Nursing home residents’ survival has been studied by several authors.[29][31][11][33]

Survival to Hospital Discharge Survival Rate of Group at Left Average Survival in Study Group Rate as Fraction of Average Subgroup Sample Size Patients
Current Total, Outside Hospitals 16% 16% 37,155 2017[7]
4-8 Major health conditions 18% 34% 0.5 98 1999-2003[32]
3 Major health conditions 24% 34% 0.7 125 1999-2003
2 Major health conditions 33% 34% 1.0 211 1999-2003
1 Major health condition 35% 34% 1.0 323 1999-2003
0 Major health conditions 43% 34% 1.3 286 1999-2003
Nursing Home (NH) Residents in Copenhagen 9% 17% 0.6 245 2007-11[11]
Current Total, Inside Hospitals 26% 26% 22,960 2016[6]
INSIDE HOSPITALS, MULTIPLE CONDITIONS, Deyo-Charlson score, higher means higher burden of chronic illness
3-33 Deyo–Charlson score, highest burden of chronic illness 16% 18% 0.9 94,608 92-05[31]
2 Deyo–Charlson score 19% 18% 1.0 116,401 92-05
1 Deyo–Charlson score, low burden of chronic illness 19% 18% 1.0 145,627 92-05
0 Deyo–Charlson score, lowest burden of chronic illness 19% 18% 1.0 77,349 92-05
Nursing home residents, mental problems, dependent 9% 16% 0.5 1,299 2000-08[33]
Nursing home residents before hospitalization 11% 16% 0.7 2,845 2000-08
Skilled nursing facility before hospital 12% 18% 0.6 10,924 92-05[31]
Nursing home or other (not a personal home) 17% 19% 0.9 34,342 2001-10[29]
Mental problems (CPC=3), dependent on others 10% 16% 0.6 4,251 2000-08[33]
Advanced Cancer 10% 18% 0.5 6,585 2006-10[30]
Cancer or blood disease 10% 19% 0.5 16,640 2001-10[29]
Liver insufficiency/failure 10% 19% 0.5 10,154 2001-10
Septicemia 11% 19% 0.5 21,057 2001-10
Dialysis 12% 19% 0.6 5,135 2001-10
Pneumonia 14% 19% 0.7 18,277 2001-10
Respiratory insufficiency 16% 19% 0.8 57,054 2001-10
Congestive heart failure 19% 19% 1.0 40,362 2001-10
Diabetes 20% 19% 1.0 41,154 2001-10
Pacemaker/ICD (implanted cardioverter defibrillator) 20% 19% 1.1 10,386 2001-10
Intensive care unit 18% 19% 0.9 81,176 2001-10
Monitored, other than ICU 25% 19% 1.3 30,100 2001-10
Unmonitored 15% 19% 0.8 22,899 2001-10
Black race 15% 19% 0.8 27,246 2001-10
<$15,000 median income in patient’s zip code 13% 18% 0.7 10,626 92-05[31]
$15-$30,000 median income in patient’s zip code 18% 18% 1.0 87,164 92-05
Patients’ ages 90 or older 12% 18% 0.7 34,069 92-05
Patients’ ages 85-89 15% 18% 0.8 62,530 92-05
Patients’ ages 80-84 17% 18% 0.9 91,471 92-05
Ventricular fibrillation (quiver) / ventricular tachycardia (rapid beat) 38% 19% 2.0 27,653 2001-10[29]
Stopped (asystole) 13% 19% 0.7 46,856 2001-10
Pulseless electrical activity 14% 19% 0.7 53,965 2001-10
Other 24% 19% 1.3 7,422 2001-10

• Outside hospitals in King County, WA, 1999-2003.[32] Others are US national data, except where noted.

Reductions in other care are not supposed to result from DNR, but they do. Some patients choose DNR because they prefer less care, so there are many doctors who construe DNR as a goal of not wanting full care, and they do not offer full care.[34]

Patients with DNR are less likely to get medically appropriate care for a wide range of issues such as blood transfusions, cardiac catheterizations, cardiac bypass, operations for surgical complication,[35] blood cultures, central line placement,[36] antibiotics and diagnostic tests.[37] “[P]roviders intentionally apply DNR orders broadly because they either assume that patients with DNR orders would also prefer to abstain from other life-sustaining treatments or believe that other treatments would not be medically beneficial.”[37] 60% of surgeons do not offer operations with over 1% mortality to patients with DNRs.[38]

Patients with DNR therefore die sooner, even from causes unrelated to CPR. A study grouped 26,300 very sick hospital patients in 2006-10 from the sickest to the healthiest, using a detailed scale from 0 to 44. They compared survival for patients at the same level, with and without DNR orders. In the healthiest group, 69% of those without DNR survived to leave the hospital, while only 7% of equally healthy patients with DNR survived. In the next-healthiest group, 53% of those without DNR survived, and 6% of those with DNR. Among the sickest patients, 6% of those without DNR survived, and none with DNR.[34]

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,[39] but within 12 hours US hospitals put up to 58% of survivors on DNR, with a median of 23% going DNR 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.[34] When CPR happened outside the hospital, hospitals put up to 80% of survivors on DNR within 24 hours, with an average of 32.5%. These patients 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.[40]

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 is a legally binding document.

Physician Orders for Life-Sustaining Treatment (POLST) documents are the usual place where a DNR is recorded. 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.[41] 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.[42]

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.[43]

There is accumulating evidence of a racial bias in 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.[44]

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.[45] 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.[46]

There are also ethical concerns around how patients reach the decision to make themselves a DNR. One study found that when questioned in more detail, many patients who were DNR actually would have wanted the excluded interventions depending on the scenario. Most would prefer life saving intubation in the scenario of angioedemawhich typically resolves in days. One fifth of the DNR patients would want resuscitation for cardiac arrest but to have care withdrawn after a week. It is possible that providers are having a “leading conversation” with patients or mistakenly leaving crucial information out when discussing DNR.[47] One study reported that physicians repeatedly give high intensity care to patients while deciding they themselves would be DNR under similar circumstances.[48]

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 ICD’s 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.[49]

DNR and Do Not Resuscitate are common terms in the United States, Canada, New Zealand and the United Kingdom. This may be clarified in some regions with the addition of DNI (Do Not Intubate), although in some hospitals DNR alone will imply no intubation. Clinically, the vast majority of people requiring resuscitation will require intubation, making a DNI alone problematic. Hospitals sometimes use the expression no code, which refers to the jargon term code, short for Code Blue, an alert 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.

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.[50][51]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,[52]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).[53]

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]

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 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?”[54] 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 USA, four respondents said Yes, and two said No.

Doctors’ Approaches to Communication about Resuscitation[54]
Country Discuss with Patient or Family Tell Other Doctors the Decision
Argentina Rarely Oral
Australia Most, Half Oral+Notes+Pre-printed (2), Notes
Austria Half Notes
Barbados Half Oral+Notes
Belgium Half, Rarely Notes+Electronic
Brazil Most Oral+Notes
Brunei Rarely Oral+Notes
Canada Always, Most Oral+Notes, Oral+Notes+Electronic, Notes+Pre-printed
Colombia Half Oral
Cuba Always Oral
Denmark Most Electronic
France Most Pre-printed,
Germany Always Oral+Notes+Electronic
Holland Half Electronic (3)
Hong Kong Always, Half Notes+Pre-printed, Oral+Notes+Pre-printed
Hungary Rarely Oral
Iceland Rarely Notes+Electronic
India Always Notes, Oral, Oral+Notes
Ireland Most, Rarely Notes (2)
Israel Most, Half Oral+Notes (2) Notes
Japan Most, Half Oral, Notes,
Lebanon Most Oral+Notes+Electronic
Malaysia Rarely Notes
Malta Most Notes
New Zealand Always Pre-printed
Norway Always, Rarely Oral, Notes+Electronic
Pakistan Always Notes+Electronic
Poland Always, Most Oral+Notes, Notes+Pre-printed
Puerto Rico Always Pre-printed
Saudi Arabia Always, Most Pre-printed, Notes+Electronic, Oral
Singapore Always, Most, Half Pre-printed (2), Oral+Notes+Pre-printed, Oral+Notes+Electronic, Oral+Pre-printed
South Africa Rarely Oral+Notes
South Korea Always Pre-printed
Spain Always, Most Pre-printed, Oral+Notes+Electronic, Oral+Notes+Pre-printed
Sri Lanka Most Notes
Sweden Most Oral+Notes+Pre-printed+Electronic
Switzerland Most, Half Oral+Notes+Pre-printed, Oral+Notes+Other
Taiwan Half, Rarely Notes+Pre-printed+Other, Oral
UAE Half Oral+Notes
Uganda Always Notes,
USA Always, Most Notes, Electronic, Oral+Electronic, Oral+Notes+Electronic, Oral+Notes+Pre-printed+Electronic

DNRs are not recognized by Jordan. Physicians attempt to resuscitate all patients regardless of individual or familial wishes.[55] 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.[56] In Saudi Arabia patients cannot legally sign a DNR, but DNR accepted by order of 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]

DNACPR form as used in Scotland

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, however any discussion is not in reference to consent to resuscitation and instead should be an explanation.[57] 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‘. 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 they lack capacity relatives will often be asked for their opinion out of respect.

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.[58]

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 of 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 individual’s decision in their healthcare.[59] 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.[60][61]

Do not resuscitate orders are similar to those used in the United States. In 1995, the Canadian Medical AssociationCanadian Hospital AssociationCanadian 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.[62] 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.[62]

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.[63]

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.[64]

DNRs are not recognized by Italy. Physicians must attempt to resuscitate all patients regardless of individual or familial wishes. Italian laws force healthcare staff to resuscitate a patient even if the patient has a DNR or does not wish to live. There are jail penalties (from 6 to 15 years) for healthcare staff breaching this law, e.g. “omicidio del consenziente”.[65][better source needed] Therefore in Italy a signed DNR has no legal value.

In Taiwan, patients sign their own DNR orders, and are required to do so to receive hospice care.[66]

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  21. ^ “CPR Breaking Bones”EMTLIFE. Retrieved 2018-12-12.
  22. Jump up to: a b “Part 8: Post-Cardiac Arrest Care – ECC Guidelines, section 11″Resuscitation Science, Section 11. 2015.
  23. ^ Bossaert; et al. (2015). “European Resuscitation Council Guidelines for Resuscitation 2015: Section 11. The ethics of resuscitation and end-of-life decisions”Resuscitation. Retrieved 2019-01-24.
  24. ^ Joseph L, Chan PS, Bradley SM, Zhou Y, Graham G, Jones PG, Vaughan-Sarrazin M, Girotra S (September 2017). “Temporal Changes in the Racial Gap in Survival After In-Hospital Cardiac Arrest”JAMA Cardiology2 (9): 976–984. doi:10.1001/jamacardio.2017.2403PMC 5710174PMID 28793138.
  25. ^ Breu AC (2018-10-01). “Clinician-Patient Discussions of Successful CPR—The Vegetable Clause”JAMA Internal Medicine178 (10): 1299–1300. doi:10.1001/jamainternmed.2018.4066ISSN 2168-6106.
  26. Jump up to: a b Orioles A, Morrison WE, Rossano JW, Shore PM, Hasz RD, Martiner AC, Berg RA, Nadkarni VM (December 2013). “An under-recognized benefit of cardiopulmonary resuscitation: organ transplantation”. Critical Care Medicine41(12): 2794–9. doi:10.1097/CCM.0b013e31829a7202PMID 23949474.
  27. ^ Sandroni C, D’Arrigo S, Callaway CW, Cariou A, Dragancea I, Taccone FS, Antonelli M (November 2016). “The rate of brain death and organ donation in patients resuscitated from cardiac arrest: a systematic review and meta-analysis”Intensive Care Medicine42 (11): 1661–1671. doi:10.1007/s00134-016-4549-3PMC 5069310PMID 27699457.
  28. ^ “Part 3: Ethical Issues – ECC Guidelines, section 3.2″. American Heart Association. Retrieved 2019-01-24.
  29. Jump up to: a b c d e Merchant RM, Berg RA, Yang L, Becker LB, Groeneveld PW, Chan PS (January 2014). “Hospital variation in survival after in-hospital cardiac arrest”Journal of the American Heart Association3 (1): e000400. doi:10.1161/jaha.113.000400PMC 3959682PMID 24487717.
  30. Jump up to: a b Bruckel JT, Wong SL, Chan PS, Bradley SM, Nallamothu BK (October 2017). “Patterns of Resuscitation Care and Survival After In-Hospital Cardiac Arrest in Patients With Advanced Cancer”Journal of Oncology Practice13 (10): e821–e830. doi:10.1200/JOP.2016.020404PMC 5640412PMID 28763260.
  31. Jump up to: a b c d e Ehlenbach WJ, Barnato AE, Curtis JR, Kreuter W, Koepsell TD, Deyo RA, Stapleton RD (July 2009). “Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly”The New England Journal of Medicine361 (1): 22–31. doi:10.1056/NEJMoa0810245PMC 2917337PMID 19571280.
  32. Jump up to: a b c Carew HT, Zhang W, Rea TD (June 2007). “Chronic health conditions and survival after out-of-hospital ventricular fibrillation cardiac arrest”Heart93 (6): 728–31. doi:10.1136/hrt.2006.103895PMC 1955210PMID 17309904.
  33. Jump up to: a b c Abbo ED, Yuen TC, Buhrmester L, Geocadin R, Volandes AE, Siddique J, Edelson DP (January 2013). “Cardiopulmonary resuscitation outcomes in hospitalized community-dwelling individuals and nursing home residents based on activities of daily living”. Journal of the American Geriatrics Society61 (1): 34–9. doi:10.1111/jgs.12068PMID 23311551.
  34. Jump up to: a b c Fendler TJ, Spertus JA, Kennedy KF, Chan PS (November 2017). “Association between hospital rates of early Do-Not-Resuscitate orders and favorable neurological survival among survivors of inhospital cardiac arrest”American Heart Journal193: 108–116. doi:10.1016/j.ahj.2017.05.017PMC 5747564PMID 29129249.
  35. ^ Horwitz LI (January 2016). “Implications of Including Do-Not-Resuscitate Status in Hospital Mortality Measures”. JAMA Internal Medicine176 (1): 105–6. doi:10.1001/jamainternmed.2015.6845PMID 26662729.
  36. ^ Smith CB, Bunch O’Neill L (October 2008). “Do not resuscitate does not mean do not treat: how palliative care and other modalities can help facilitate communication about goals of care in advanced illness”. The Mount Sinai Journal of Medicine, New York75 (5): 460–5. doi:10.1002/msj.20076PMID 18828169.
  37. Jump up to: a b Yuen JK, Reid MC, Fetters MD (July 2011). “Hospital do-not-resuscitate orders: why they have failed and how to fix them”Journal of General Internal Medicine26 (7): 791–7. doi:10.1007/s11606-011-1632-xPMC 3138592PMID 21286839.
  38. ^ Schwarze ML, Redmann AJ, Alexander GC, Brasel KJ (January 2013). “Surgeons expect patients to buy-in to postoperative life support preoperatively: results of a national survey”Critical Care Medicine41 (1): 1–8. doi:10.1097/CCM.0b013e31826a4650PMC 3624612PMID 23222269.
  39. ^ “Resuscitation, Item 7.1, Prognostication”CPR & ECC Guidelines. The American Heart Association. Part 3: Ethical Issues – ECC Guidelines, Timing of Prognostication in Post–Cardiac Arrest Adults
  40. ^ Richardson DK, Zive D, Daya M, Newgard CD (April 2013). “The impact of early do not resuscitate (DNR) orders on patient care and outcomes following resuscitation from out of hospital cardiac arrest”. Resuscitation84 (4): 483–7. doi:10.1016/j.resuscitation.2012.08.327PMID 22940596.
  41. ^ Coleman D (2013-07-23). “Full Written Public Comment: Disability Related Concerns About POLST”Not Dead Yet. Retrieved 2018-12-12.
  42. ^ Jesus JE, Allen MB, Michael GE, Donnino MW, Grossman SA, Hale CP, Breu AC, Bracey A, O’Connor JL, Fisher J (July 2013). “Preferences for resuscitation and intubation among patients with do-not-resuscitate/do-not-intubate orders”. Mayo Clinic Proceedings88 (7): 658–65. doi:10.1016/j.mayocp.2013.04.010PMID 23809316.
  43. ^ Dugan D, Riseman J (July 2015). “Do-Not-Resuscitate Orders in an Operating Room Setting #292″. Journal of Palliative Medicine18 (7): 638–9. doi:10.1089/jpm.2015.0163PMID 26091418.
  44. ^ Garrido MM, Harrington ST, Prigerson HG (December 2014). “End-of-life treatment preferences: a key to reducing ethnic/racial disparities in advance care planning?”Cancer120 (24): 3981–6. doi:10.1002/cncr.28970PMC 4257859PMID 25145489.
  45. ^ Humble MB (November 2014). “Do-Not-Resuscitate Orders and Suicide Attempts: What Is the Moral Duty of the Physician?”. The National Catholic Bioethics Quarterly14 (4): 661–71. doi:10.5840/ncbq201414469.
  46. ^ Hébert PC, Selby D (April 2014). “Should a reversible, but lethal, incident not be treated when a patient has a do-not-resuscitate order?”CMAJ : Canadian Medical Association Journal = Journal de l’Association Medicale Canadienne186(7): 528–30. doi:10.1503/cmaj.111772PMC 3986316PMID 23630240.
  47. ^ Capone RA (March 2014). “Problems with DNR and DNI orders”. Ethics & Medics39 (3): 1–3.
  48. ^ Pfeifer M, Quill TE, Periyakoil VJ (2014). “Physicians provide high-intensity end-of-life care for patients, but “no code” for themselves”Medical Ethics Advisor30(10).
  49. ^ Daeschler M, Verdino RJ, Caplan AL, Kirkpatrick JN (August 2015). “Defibrillator Deactivation against a Patient’s Wishes: Perspectives of Electrophysiology Practitioners”. Pacing and Clinical Electrophysiology38 (8): 917–24. doi:10.1111/pace.12614PMID 25683098.
  50. ^ Mockford C, Fritz Z, George R, Court R, Grove A, Clarke B, Field R, Perkins GD (March 2015). “Do not attempt cardiopulmonary resuscitation (DNACPR) orders: a systematic review of the barriers and facilitators of decision-making and implementation”Resuscitation88: 99–113. doi:10.1016/j.resuscitation.2014.11.016PMID 25433293.
  51. ^ Meyer C. “Allow Natural Death — An Alternative To DNR?”. Rockford, Michigan: Hospice Patients Alliance.
  52. ^ Pollak AN, Edgerly D, McKenna K, Vitberg DA, et al. (American Academy of Orthopaedic Surgeons) (2017). Emergency Care and Transportation of the Sick and Injured. Jones & Bartlett Learning. p. 540. ISBN 978-1-284-10690-9.
  53. ^ Vincent JL, Van Vooren JP (December 2002). “[NTBR (Not to Be Resuscitated) in 10 questions]“. Revue Medicale de Bruxelles23 (6): 497–9. PMID 12584945.
  54. Jump up to: a b “Themes and variations: An exploratory international investigation into resuscitation decision-making”Resuscitation103: 75–81. 2016-06-01. doi:10.1016/j.resuscitation.2016.01.020ISSN 0300-9572.
  55. ^ “Mideast med-school camp: divided by conflict, united by profession”The Globe and Mail. August 2009. Retrieved 2009-08-22In hospitals in Jordan and Palestine, neither families nor social workers are allowed in the operating room to observe resuscitation, says Mohamad Yousef, a sixth-year medical student from Jordan. There are also no DNRs. “If it was within the law, I would always work to save a patient, even if they didn’t want me to,” he says.
  56. ^ Al Amir S (25 September 2011). “Nurses deny knowledge of ‘do not resuscitate’ order in patient’s death”The National. United Arab Emirates. Retrieved 12 April2018.
  57. ^ “Decisions relating to cardiopulmonary resuscitation: A joint statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing” (PDF) Resuscitation Council (UK). Retrieved 17 June2014.
  58. ^ Scottish Government (May 2010). “Do Not Attempt Cardiopulmonary Resuscitation (DNACPR): Integrated Adult Policy” (PDF). NHS Scotland.
  59. ^ Eckberg E (April 1998). “The continuing ethical dilemma of the do-not-resuscitate order”AORN Journal. Retrieved 2009-08-23The right to refuse or terminate medical treatment began evolving in 1976 with the case of Karen Ann Quinlan v New Jersey (70NJ10, 355 A2d, 647 [NJ 1976]). This spawned subsequent cases leading to the use of the DNR order.(4) In 1991, the Patient Self-Determination Act mandated hospitals ensure that a patient’s right to make personal health care decisions is upheld. According to the act, a patient has the right to refuse treatment, as well as the right to refuse resuscitative measures.(5) This right usually is accomplished by the use of the DNR order.
  60. ^ “DO NOT RESUSCITATE – ADVANCE DIRECTIVES FOR EMS Frequently Asked Questions and Answers”State of California Emergency Medical Services Authority. 2007. Archived from the original on 2009-08-23. Retrieved 2009-08-23# What if the EMT cannot find the DNR form or evidence of a MedicAlert medallion? Will they withhold resuscitative measures if my family asks them to? No. EMS personnel are taught to proceed with CPR when needed, unless they are absolutely certain that a qualified DNR advance directive exists for that patient. If, after spending a reasonable (very short) amount of time looking for the form or medallion, they do not see it, they will proceed with lifesaving measures.
  61. ^ “Frequently Asked Questions re: DNR’s”New York State Department of Health. 1999-12-30. Retrieved 2009-08-23May EMS providers accept living wills or health care proxies? A living will or health care proxy is NOT valid in the prehospital setting
  62. Jump up to: a b “Do Not Resuscitate Orders”. Princess Margaret Hospital d. Archived from the original on 2014-07-15. Retrieved 2012-12-05.
  63. ^ “Respect for the right to choose – Resources”. Dying with dignity, Victoria. 2017. Retrieved 2017-06-14.
  64. ^ “Using resuscitation plans in end of life decisions” (PDF). Government of New South Wales Health Department. 2014-09-08. Retrieved 2017-06-14.
  65. ^ it:Omicidio del consenziente (ordinamento penale italiano)
  66. ^ Fan SY, Wang YW, Lin IM (October 2018). “Allow natural death versus do-not-resuscitate: titles, information contents, outcomes, and the considerations related to do-not-resuscitate decision”BMC Palliative Care17 (1): 114. doi:10.1186/s12904-018-0367-4PMC 6180419PMID 30305068.

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