In reply

Abstract

Editors note:—The above letter was referred to the authors of the initial paper, and Dr. Finucane's reply follows. In reply:—Dr. Dudley has raised an important point, for which we thank him. Our statement is misleading and should more correctly have read that “current policy in many US nursing home implies that cardiopulmonary resuscitation (CPR) should be attempted…” The means by which putatively “life-sustaining treatments” may be withheld have become the province of attorneys general and special-interest groups almost as much as physicians. Because the death of a patient is potentially bad press and a liability exposure for some hospital administrators and attorneys, we believe that these people may be likely to give very conservative advice about withholding CPR,1 and that this advice often becomes policy. At the level of anecdotes, in the Veterans Administration medical system, nursing homes are attached to hospitals and follow the hospitals’ policies. These policies usually require CPR in the absence of a Do Not Resuscitate (DNR) order [Joan Treuer, MD, personal communication). New York state regulations require that, absent a DNR order, nursing home staff should initiate CPR and/or call an ambulance if a resident appears lifeless. The only exceptions are rigor mortis, decapitation, or overwhelming burns (Paul Katz, MD, personal communcation.) Several studies have tabulated the numbers of nursing homes that have policies about resuscitation or that accept DNR orders. None of these articles specify what should happen to patients who are not “covered” by a DNR order.2-5 It is only inference, however, that these homes require CPR as a policy matter in the absence of a DNR order. In informal conversation many other physicians have described similar policies. Two or three have described a policy which “excuses” the nursing home staff from attempting CPR if the arrest is unwitnessed. We believe that a certain legal logic contributes to this serious impasse. If only a physician can declare a patient dead, then a nurse or an ambulance driver can only encounter a live person, albeit one who may be pulseless and apneic. Attempting CPR is the logical next step. Physician timidity and bureaucratic conservatism have not as yet led to explicit pro-active solutions. With the very limited exceptions noted above, we are not aware of any policy that specifically permits CPR to be withheld for any reason other than a DNR order. In summary, then, policies about CPR in nuring homes are heterogeneous, constantly evolving, and often vague. Under what conditions a potentially “life-sustaining therapy” may be withheld are unclear, and the “default” position in the US is often to “do it all,” sometimes with little regard for the particular circumstances of the patient. We would be most interested in how our British colleagues resolve this frequent contradiction between common sense and (implicit or express) policy.