If You’re Over 70, Why Your Doctor Should Order DNR/AND on Admission to Hospital or LTC

For anyone admitted to hospital or into LTC, when their heart stops they will automatically receive CPR (CardioPulmonary Resuscitation) unless there is an order to Allow Natural Death (AND) or DNR.  For this age group, especially if they have a life-limiting disease (ESRD, ESLD, CHF, most metastatic cancers, AIDS, ALS, Alzheimers liver failure), an AND/DNR order is appropriate for the following reasons:

1. CPR is a non-beneficial or futile procedure in this group.  (a „futile. procedure is defined as one which will not help a patient reach their goal, or one with a <5% chance of survival.
[Davila F. The infinite costs of futile care… Physician Exec. 2006])

2. In hospital, only 2-17% of all seniors arresting will survive to discharge and half of those have a worse quality of life and testify that they wish they had not been resuscitated.  In LTC, the survival rate is worse. 
[(1) Murphy DJ.  Outcomes of CPR in the elderly. Ann Intern Med. 1989; (2) Waisel DB.  The CPR-not-indicated order:  futility revisited.  Ann Intern Med. 1995.  (3) Brindley PG. Predictors of survival following in-hospital adult CPR. CMAJ 2002.  (4) Peberdy MA. CPR of adults in the hospital. Resuscitation. 2003.  (5) Swor RA. Does advanced age matter in outcomes after out-of-hospital cardiac arrest in community-dwelling adults? Acad Emerg Med. 2000. (6) Benkendorf R. Outcomes of cardiac arrest in the nursing home: destiny or futility? Prehosp Emerg Care 1997]

3. CPR is a harsh procedure incompatible with a peaceful death; and offers only false hope when we should be helping families prepare for the final stage in life.

4. Although most will develop signs of approaching death which allows an opportunity to write an AND/DNR, many patients have an unpredictable crisis (often in the middle of the night!) resulting in unwanted CPR.

5. Seniors with such chronic diseases (and their families) do not want the dying process prolonged; they want honest information, to be comfortable, to be listened to, and to be part of the decision-making process. 
[(1) Singer PA. Quality end-of-life care: patients’ perspectivies. JAMA. 1999 Jan 13.  (2) Steinhauser KE. Factors considered important at the end-of-life by patients, family, physicians, and other care providers. JAMA. 2000Nov 15. (3) Fried TR. Understanding the treatment preferences of seriously ill patients. NEJM 2002 Apr 4.]

6. Physicians are not ethically obligated to provide a futile treatment to any patient, even if they request it
[AMA’s Ethical Guidelines].

7. Patients expect their physician to discuss EOLC issues with them.

Thus, the evidence overwhelmingly leads us to conclude that physicians, after discussing this issue with their patients and providing supporting information, should order AND/DNR for those with life-limiting diseases – if not for all seniors.  (AND is a more acceptable, dignified, and appropriate term to many)

Several articles are available on this website to help physicians and patients in these decisions, especially the Allowing for Natural Death – Myth & Reality; and the booklet by Hank Dunn, Hard Choices for Loving People, is worth obtaining.