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Correspondence |

Cardiopulmonary Resuscitation at the End of Life Without Patient Consent : An Ethical Challenge to Autonomy and Self-Determination FREE TO VIEW

Mohamed Y. Rady, MD, PhD; Joseph L. Verheijde, PhD, MBA, PT; Joan L. McGregor, PhD
Author and Funding Information

Affiliations: Department of Critical Care Medicine,  Department of Physical Medicine and Rehabilitation, Mayo Clinic Hospital, Phoenix, AZ,  Department of Philosophy, Arizona State University, Tempe, AZ

Correspondence to: Mohamed Y. Rady, MD, PhD, Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 East Mayo Blvd, Phoenix, AZ 85054; e-mail: rady.mohamed@mayo.edu



Chest. 2008;133(1):320. doi:10.1378/chest.07-2393
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To the Editor:

We agree that clinicians must disclose all relevant information to patients and families in a manner that they can understand in order to decide voluntarily what can or cannot be done to them. If assent and/or consent process can fulfil this goal, then the patient’s rights of autonomy and self-determination are preserved.12

It is a federal requirement that advanced health-care directives including resuscitation preferences are discussed with patients and documented when admitted to Medicare-approved health-care facilities.3In the absence of such discussions, defaulting to cardiopulmonary resuscitation (CPR) at the end of life can be equally unethical and infringe on the right of self-determination. Revoking do-not-resuscitate preference unilaterally and performing CPR at the end of life without informed consent not only interrupt a peaceful death but also expose clinicians to the risk of future liabilities.4

In 2003, the Association of Organ Procurement Organizations requested the revision of the Uniform Anatomical Gift Act (UAGA) to increase deceased organ procurement.5The revised UAGA (2006) has been enacted in many states.6 The UAGA defaults an individual to be a potential donor of organs for transplantation (unless opted out by a signed refusal). Currently, CPR is the default procedure at or near death. Once resuscitation and life support therapy have been initiated, therapy cannot be withdrawn until an evaluation of the individual as a prospective organ donor has been completed by the procurement personnel (section 14 of UAGA 2006).6 Life support therapy to ensure medical suitability of organs for transplantation in a prospective donor cannot be withheld or withdrawn and overrides contrary wishes expressed in advanced directives (section 21 of UAGA 2006).6The discussion of CPR with patients and families must also address and document their preferences about life support therapy at the end of life for the purpose of organ donation.7

The authors have no conflicts of interest to disclose.

Curtis, JR, Burt, RA (2007) Point: the ethics of unilateral “do not resuscitate” orders; the role of “informed assent.”Chest132,748-751. [PubMed] [CrossRef]
 
Manthous, CA Counterpoint: is it ethical to order “do not resuscitate” without patient consent?Chest2007;132,751-754. [PubMed]
 
Code of Federal Regulations. Title 42–Public Health-Chapter IV–Centers for Medicare and Medicaid Services, Department of Health and Human Services, 42CFR489.100. Subpart I– Advance Directives. Available at: http://a257.g.akamaitech.net/7/257/2422/05dec20031700/edocket.access.gpo.gov/cfr_2003/octqtr/pdf/42cfr489.100.pdf. Accessed September 26, 2007.
 
Sorrel AL. Lawsuit showcases DNR liability twist for doctors: medical and legal experts say the case raises issues about the standard of care with end-of-life directives. Available at:http://www.ama-assn.org/amednews/2007/02/05/prl20205.htm. Accessed September 26, 2007.
 
Association of Organ Procurement Organizations. Letter to National Conference of Commissioners on uniform state laws. Available at: http://www.aopo.org/aopo/content/archives/update/2003Fall/UniformAnatomicalGiftAct102203.html. Accessed September 26, 2007.
 
National Conference of Commissioners on uniform state laws: revised Uniform Anatomical Gift Act (2006). Available at: http://www.anatomicalgiftact.org/DesktopDefault.aspx?tabindex=0&tabid=1. Accessed September 26, 2007.
 
Verheijde JL, Rady MY, McGregor JL. The United States revised Uniform Anatomical Gift Act (2006): new challenges to balancing patient rights and physician responsibilities. Available at: http://www.peh-med.com/content/2/1/19. Accessed November 18, 2007.
 

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References

Curtis, JR, Burt, RA (2007) Point: the ethics of unilateral “do not resuscitate” orders; the role of “informed assent.”Chest132,748-751. [PubMed] [CrossRef]
 
Manthous, CA Counterpoint: is it ethical to order “do not resuscitate” without patient consent?Chest2007;132,751-754. [PubMed]
 
Code of Federal Regulations. Title 42–Public Health-Chapter IV–Centers for Medicare and Medicaid Services, Department of Health and Human Services, 42CFR489.100. Subpart I– Advance Directives. Available at: http://a257.g.akamaitech.net/7/257/2422/05dec20031700/edocket.access.gpo.gov/cfr_2003/octqtr/pdf/42cfr489.100.pdf. Accessed September 26, 2007.
 
Sorrel AL. Lawsuit showcases DNR liability twist for doctors: medical and legal experts say the case raises issues about the standard of care with end-of-life directives. Available at:http://www.ama-assn.org/amednews/2007/02/05/prl20205.htm. Accessed September 26, 2007.
 
Association of Organ Procurement Organizations. Letter to National Conference of Commissioners on uniform state laws. Available at: http://www.aopo.org/aopo/content/archives/update/2003Fall/UniformAnatomicalGiftAct102203.html. Accessed September 26, 2007.
 
National Conference of Commissioners on uniform state laws: revised Uniform Anatomical Gift Act (2006). Available at: http://www.anatomicalgiftact.org/DesktopDefault.aspx?tabindex=0&tabid=1. Accessed September 26, 2007.
 
Verheijde JL, Rady MY, McGregor JL. The United States revised Uniform Anatomical Gift Act (2006): new challenges to balancing patient rights and physician responsibilities. Available at: http://www.peh-med.com/content/2/1/19. Accessed November 18, 2007.
 
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