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Ethics and Medico Legal Aspects of Not for Resuscitation

Indian J Palliat Care. 2010 May-Aug; 16(2): 6669.

PMCID: PMC3144433

doi: 10.4103/0973-1075.68404

Ethics and Medico Legal Aspects of Not for Resuscitation


Naveen Sulakshan Salins, Sachin Gopalakrishna Pai,1 MS Vidyasagar,2 and Manikkath Sobhana3
Palliative Medicine Consultant, Palliative Medicine Unit, Departments of Radiotherapy and Oncology, Shiridi SaiBaba Cancer Hospital and Research
Centre, KMC Manipal, Manipal University 576104, India
1
Assistant Professor, Department of Medical Oncology, Shiridi SaiBaba Cancer Hospital and Research Centre, KMC Manipal, Manipal University
576104, India
2
Professor, Department of Radiotherapy and Oncology, Shiridi SaiBaba Cancer Hospital and Research Centre, KMC Manipal, Manipal University
576104, India
3
Medical Social Worker, Department of Radiotherapy, and Oncology, Shiridi SaiBaba Cancer Hospital and Research Centre, KMC Manipal, Manipal
University 576104, India
Address for correspondence: Dr. Naveen Sulakshan Salins; E-mail: naveensalins@gmail.com
Copyright Indian Journal of Palliative Care
This is an open-access article distributed under the terms of the Creative Commons Attribution License, w hich permits unrestricted use, distribution,
and reproduction in any medium, provided the original w ork is properly cited.
This article has been cited by other articles in PMC.

Abstract

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Not for resuscitation in India still remains an abstract concept with no clear guidelines or legal frame work.
Cardiopulmonary resuscitation is a complex medical intervention which is often used inappropriately in
hospitalized patients and usually guided by medical decision making rather than patient-directed choices.
Patient autonomy still remains a weak concept and relatives are expected to make this big decision in a short
time and at a time of great emotional distress. This article outlines concepts around ethics and medico legal
aspects of not for resuscitation, especially in Indian setting.
Keywords: Autonomy, Cardiopulmonary resuscitation, Ethics, Law
Life sustaining treatment is defined as any medical intervention, technology, procedure or medication that is
administered to a patient in order to forestall the moment of death, whether or not the treatment is intended
to affect the underlying life threatening disease or biological process. Decisions to withhold life-sustaining
treatment are made in two different situations. In the first, treatment is withheld from an actively dying
person whose existing condition indicates that effective cardiopulmonary resuscitation (CPR) is unlikely to be
successful or a successful CPR is likely to be followed by a length and quality of life that would not be in best
interests of patient to sustain. In the second, the decision is hypothetical, whereby the withholding of
treatment is made in advance, in a situation where a life threatening condition may eventuate.[1]
Cardiopulmonary resuscitation (CPR) came into widespread use in 1960s and soon it was apparent that it
was inappropriately used in some patients most obviously in advanced metastatic malignancy, end stage
organ failure and severe sepsis. CPR is a form of intensive and invasive treatment associated with high
mortality. Compared to other treatments, this intensive treatment is poorly discussed and documented.[2]
When a patient suffers sudden cardiopulmonary arrest usually, the decision whether or not to resuscitate
depends upon the physicians professional appraisal of the likelihood of successfully restoring
cardiopulmonary functioning of a particular patient versus the probable futility of a resuscitative attempt.
However, ethical, legal and sometimes financial implications must be taken into account. The issue of
resuscitation raises fundamental ethical questions about autonomy (patients wishes and choices),
beneficence (appropriate decision making), non -maleficence (harm avoidance) and justice (allocation of
limited resources). Medico legal aspects of CPR deal with issues such as competency of an individual in
decision-making, standards and processes of decision-making and dilemmas in instituting or withholding
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CPR in an incompetent individual.[3]


In the western world, more than 90% of patients reported to have information about CPR from television.
Patients often overestimated their likelihood of survival after CPR and this misinformation often led to
choosing resuscitation in situations in which successful outcomes were extremely unlikely.[4,5] A study of
popular medical dramas projected an unusually high survival rate following a CPR in contrary to the actual
figures.[6] Often patients and patients relatives participate in decisions about resuscitation and end of life at
a time of great emotional distress. In a short period of time, they are expected to digest and evaluate complex
medical information and make decisions about themselves or for the loved ones. Therefore, prior knowledge,
information and media portrayal strongly influence the decision making.[7] A study reported that 50% of
elderly patients, who first chose to be resuscitated, changed their opinion after they received more detailed
information about the CPR process and possibility of surviving.[5] Educational intervention consisting of
handouts and a videotape about advance directives improved knowledge and intended to change attitudes
and behavior about resuscitation.[8] It is important for the physicians to explain the process, clinical
accompaniments and aftermath including intubation, mechanical ventilation, artificial feeding, hydration,
supplemental oxygen and pharmacological agents. Therefore, decision of instituting CPR is not a single
ethical decision but a number of choices either bundled together or spread over a period of time.[9]
In the past, issuing a not for resuscitation order was considered as a part of doctors therapeutic prerogative
and was often not formally registered. This practice still exists in many places and countries. The main ethical
problems with such informal practices are that they exclude patients and relatives from the process of
decision-making process and give paternalistic doctors absolute power over the patient.[10] A Hungarian
study showed that medical practice in that country is rather paternalistic and the most important factor
influencing the decision of not for resuscitation was the opinion of the doctor in charge.[11] Indian medical
practice works on similar lines. Resuscitation status should not be just based on medical grounds and value
input from patients and families should always be considered. Successful outcomes of resuscitation mean
restoration of patients health to their pre-arrest state. Hence, resuscitation must be instituted in only those
patients where there is a reasonable chance of restoring cardiopulmonary functions, optimal mental capacity
and length and quality of life that would be in the best interests of patients to sustain.[12] CPR is considered
futile if its purpose cannot achieve reasonable length and quality of life and qualitative definition of futility
must include low chance of survival and low quality of life afterward. The framework for decisions about
futility can be best achieved by accurate prognostication, good communication, respecting patient choices,
value opinion of other healthcare providers, local society factors, and cultural and social consensus.[13] In
2005, The Royal College of Anesthetics, Physicians, Intensive Care Society and Resuscitation Council (UK)
published new resuscitation standards. The recommendations made it mandatory: (a) to identify patients in
whom cardiopulmonary arrest is an anticipated terminal event and institution of CPR is inappropriate (b) for
all institutions should ensure that there is a clear and explicit resuscitation plan for all patients (c) when there
is no resuscitation plans and wishes of the patient are unknown, the resuscitation decision should be made by
the attending medical emergency team in the best interests of the patient.[14]
Patient autonomy should be cornerstone in deciding about patients resuscitation status. Accurate
information about the condition, prognosis, and nature of the proposed intervention, alternatives, risks and
benefits may enable the patients to make better decisions about resuscitation and end of life. Physicians
seldom discuss advance directives even with their seriously ill patients.[15] Advance directives are the term
applied to any expression of a persons thoughts, wishes, or preferences for his or her end of life care. It
usually specifies nature and extent of care and it could be based on conversations, written directives, and
living will or through medical power of attorney. In a living will, the patient gives directions to physicians
about provision of medical care should the patient become terminally ill and unable to make decisions.
Competent patients in anticipation of future incompetence could appoint a family member or friend as a
surrogate decision maker and grant durable power of attorney that allows them to take medical decisions for
the patient if he or she loses the capacity to make their decisions. Surrogate decision makers should always
base their decisions on patients previously expressed wishes. Physicians can always override the decisions of
the surrogate decision makers if these decisions are not made in the best interests of the patient. It is
important to explore the opinions of surrogate decision makers and provide them knowledge and information
to make the best possible decision. If there are non-negotiable difference of opinion between doctors and
surrogate decision makers regarding appropriateness of resuscitation, then it should be further explored and
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should always be referred to the hospital ethics committee.[16,17] Decision making by doctors regarding
resuscitation and end of life care depends upon patient-dependent factors and personal characteristics of
doctor. Doctors should be open to discuss end of life preferences openly with other health care providers and
surrogate decision makers. Junior doctors in training would benefit from the supervision of the experienced
colleagues in dealing with process of end of life care and not for resuscitation.[18,19]
The first hospital policies on not for resuscitation were published in medical literature in 1976. Results from
the MERIT study showed that in UK 22% of patients attended by a medical emergency team (MET) team are
issued not for resuscitation order at the time or after a MET call and in Australia 23% of all MET calls were
appropriate for not for resuscitation order and 3.8% of the patients were issued not for resuscitation order
during the time of medical emergency team attendance.[20] Dutch hospital study showed medical staff were
poorly documenting not for resuscitation orders. The possible barriers for limited documentation were: (a)
inability to discuss resuscitation decisions (b) lack of knowledge about the facts and consequences of
resuscitation and (c) unwillingness to make resuscitation open for discussion.[21]
An American hospital study identified similar barriers for not documenting not for resuscitation and in
addition other barriers were: (d) not expecting the patient to die during admission (e) waiting for the patients
own doctor (f) not having enough knowledge about a particular patient (g) not finding the right moment or
spot to discuss it and (h) just forgetting about it.[22]
In India there is no formal process of discussion and documentation of not for resuscitation. Patient
autonomy still remains a weak concept and surrogate decision making by the next of kin or the financial
provider usually overrides patient wishes.[23] Up to 80% of the health care bills are paid by the patients and
less than 20% depend on the public health care, which is severely crippled with acute bed shortages and lack
of infrastructure. Socio-economic considerations complicate patient autonomy, issues around resuscitation
and delivery of end of life care.[24] The Indian Society of Critical Care Medicine in 2005 proposed guidelines
for limiting life-prolonging interventions and providing palliative care at end of life. The doctors are morally
and ethically obliged to provide good prognostication and initiate discussions around treatment options,
benefits of life prolonging treatment, and resuscitation. Patients and relatives should be well informed about
realistic outcomes of a disease modifying treatment, withholding and withdrawing treatment.[25] In 2002,
122 Indian physicians participated in a study that evaluated physicians beliefs regarding end of life care.
Majority of physicians did not apply not for resuscitation order and in most of the cases applied these were
primarily discussed with the family. In 2008, AIIMS study, 40 Indian pediatricians participated in end of life
survey and the 3 major factors influencing withholding support in a critically ill child was a) childs likelihood
of survival b) potential for neurologically intact survival and c) quality of life. The results of Indian
pediatricians end of life practice survey showed that 45% of pediatricians initiated not for resuscitation
orders in a dying child. 55% of them withheld active treatment and none had withdrawn active treatment.
Prognosis and limiting life prolonging measures were discussed with the families. Other clinical units and
supervisors were consulted during discussion about ethics of not for resuscitation. The study of deaths in
Indian ICU setting showed only 22% had life limiting management when compared to 74% in the western
setting. Among the 298 deaths only 4 had Not for resuscitation orders.
Left against medical advice (LAMA) is a common situation seen in Indian setting where family unilaterally
withdraws treatment due to financial constraints.
Indian Society of Critical Care Medicine in 2005 put forth a position paper outlining guidelines for not for
resuscitation in an Indian setting. The recommendations were a) Duty of the physician to discuss with
honest and clarity regarding prognosis and treatment options b) When the fully informed capable patient or
family desires to consider palliative care, the physician should offer the available modalities of limiting lifeprolonging interventions c) Physician must discuss the implications of forgoing aggressive interventions
through formal conferences with the capable patient or family, and work toward a shared decision-making
process d) If there is a conflict then pending consensus all active treatment should continue e) Responsibility,
initiation and implementation of decision of not for resuscitation rests with the treating physician f) Clear
documentation of the decision, directives and end of life wishes h) Withdrawal of life support should be
consistent with good practice, ethically right and within the limits of existing law i) Physician is obliged to
provide compassionate and effective palliative care to the patient and family. The absence of guidelines for
withdrawal and withholding of life support in Indian law is perceived to be the most important obstacle for
providing good end of life care. The study found that the barriers for providing good end of life care were
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primarily legal, administrative and lack of hospital policies and were not due to ethical and cultural barriers.
[26] Indian legal system maintains an ambiguous stance towards issues relating to limiting life support,
withholding and withdrawing treatment and resuscitation. The Supreme Court of India in 1994 ruled that
an attempt to hasten death in terminal illness might be viewed as a natural process. A person cannot be
forced to enjoy the right of life to his detriment, disadvantage or dislike.[27] The above judgment of the
Supreme court was overruled by the Constitution bench which ruled that permitting termination of life in the
dying or vegetative state is not compatible with Article 21 of the Constitution which states that No person
shall be deprived of his life or personal liberty except according to procedure established by law.[27] The
interpretation of Gian Kaur case disallows the concept of Euthanasia as it violates Article 21 of the Indian
Constitution. As withholding and withdrawing life support amounts to abetment of suicide and abetment of
suicide is a punishable offence according to Indian Penal Code. These issues are addressed by the Law
commission of India and until such laws come into effect patient autonomy, family wishes and medical
decision making at end of life will still remain guided by the Indian Penal Code.[24]

Footnotes

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Source of Support: Nil


Conflict of Interest: None declared.

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Articles from Indian Journal of Palliative Care are provided here courtesy of Medknow Publications

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