Purpose

The goal of Trauma-Critical Care is to provide high quality medical care to sustain life and to help make unavoidable death as dignified and pain-free as possible. We also recognize the right of patients to self-determination. In some circumstances aggressive medical intervention may not constitute appropriate treatment. The patient (or patient's surrogate) has the right to receive sufficient information in order to make this decision. When the patient does not wish such treatment or when the burden of such treatment outweighs the benefit, intervention should not be instituted. In these circumstances, limitation or withdrawal of life-sustaining treatment is in no way inconsistent with the overall caring mission.

Application

Physicians are encouraged to discuss the patients thoughts and preferences regarding the initiation or withdrawal of life-sustaining therapy with them, and to encourage them to discuss these matters with their families, Health Care Agents, or friends, as appropriate.

If life-sustaining treatment has been or could be initiated but, in the attending physician's exercise of clinical judgment, the initiation or continuance of such treatment would be ineffective, the attending physician or designee should discuss with the patient (where possible) or the patient's family or other surrogate decision maker, the option to withhold, withdraw, or limit such treatment. Ineffective, in this context, means that such treatment, in the considered clinical judgment of the physician responsible for its administration, would fail to produce a result which in the patient's view, as understood by the physician, would constitute meaningful survival.

If no treatment limitation is noted in the patient's chart, the presumption will be that life-sustaining interventions, including cardiopulmonary resuscitation (CPR), will be initiated. A Do Not Attempt Resuscitation must be in-place if CPR is not to be initiated.

Exceptions

This summary is intended as a guideline to cover the usual situation. It is possible, that in the exercise of appropriate clinical judgment and good medical practice, there may be deviations from this approach. In such a case, it is advisable for the attending physician to discuss the case with other clinicians, and/or the General Counsel before deviating from these guidelines.

Procedure

The following procedures must be followed and documented in the medical record prior to institution of a plan to withhold, withdraw or limit life-sustaining therapy:

I. Medical Assessment: There should be a thorough assessment in the medical record of the patient's diagnosis, condition, prognosis and treatment options.

II. Determination of Patient Competency: The attending physician should evaluate and document the competency of the patient to make informed decisions about treatment in accordance with the following guidelines.

The Competent Patient

1. A competent patient, for the purpose of these guidelines, is an adult over the age of eighteen, or an emancipated minor, who has adequate decision making capacity and has the ability to appreciate the consequences of a decision concerning resuscitation or withdrawing, withholding, or limiting therapy.

2. A competent patient may make a decision at any time concerning withholding, withdrawing, or limiting therapy or an order for DNAR. The decision should be informed and made after consultation with the attending physician regarding diagnosis, prognosis, risk, benefits and consequences of maintaining or withdrawing life-sustaining treatments. The patient can then best determine whether continuing, withdrawing, or limiting therapy is desired. If there is a question about a patient's competence, an appropriate consultation may be ordered or the situation should be discussed with the Office of the General Counsel or medical ethicist.

3. If the patient is competent, the approval of the family, Health Care Agent, or other surrogate is not required. A contrary decision by the family, Health Care Agent, or other surrogate is not sufficient to overrule the informed decision of the patient. Similarly, if the patient is incompetent but has appointed a Health Care Agent, approval of the family, or other surrogate is not required. A contrary decision by the family of an incompetent patient is not sufficient to overrule the informed decision of the Health Care Agent.

The Incompetent Patient

1. An incompetent patient, for the purposes of these guidelines, is a patient who is under eighteen years of age and not emancipated, or because of impaired mental status lacks the ability to appreciate consequences of a decision concerning resuscitation or withholding, withdrawing, or limiting therapy.

2. When treating an incompetent patient it is appropriate to consider the option of withholding, withdrawing or limiting life-sustaining treatments when in the attending physician's exercise of considered medical judgment such treatments would be ineffective as defined above in the policy statement. Such an option, including an order for DNAR, should be considered for an incompetent patient in accordance with paragraphs (3) through (9) below

3. When prior to becoming incompetent, the patient has expressed a wish that life-sustaining treatments be withheld, withdrawn, or limited if such treatment would be ineffective as defined above, the attending physician may then withhold, withdraw, or limit such treatments or execute a DNAR order. The physician should communicate with the patient's family prior to effectuating the patient's wishes.

4. If the patient has executed a Health Care Proxy, the attending physician should follow the decision of the designated Health Care Agent unless the decision is inconsistent with any limitation set forth in the Proxy. The physician should consult with the Health Care Agent who, by the Proxy, is given authority to make health care decisions for the patient. A copy of the proxy must be filed within the medical record. If there is a question about the validity of the proxy, or where the proxy contains restrictions that are not clear, the physician should review the document with Office of the General Counsel.

5. If the patient has a court appointed Guardian, the attending physician should follow the decision of the Guardian. The physician should consult with the Guardian who has authority to make most health care decisions for the patient. Copies of guardianship papers must be filed within the medical record. If there is a question regarding the scope or validity of the Guardianship, the physician should review the document with the Office of the General Counsel.

6. The Health Care Agent or other surrogate and the attending physician should jointly discuss the patient's diagnosis, prognosis, treatment, risks, and benefits, as well as available medical options in making decisions to withhold, withdraw, or limit life-sustaining treatment. Where appropriate, the physician should offer assistance from pastoral care and other specialists in helping the Agent, family or other surrogate decision maker.

7. When the physician does not have any evidence of a prior wish of the patient, and there is no Health Care Agent or Guardian, the physician should discuss the situation with the patient's family or closest surrogate and ascertain what the patient would want if the patient were competent to make a decision about withholding, withdrawing, or limiting life-sustaining therapy. When the family or surrogate can provide direction as to what the patient would want, then an order may be written consistent with that direction.

8. When after well-documented efforts to identify a Health Care Agent, Guardian, family or close friend to provide evidence regarding the patient's wishes is unsuccessful, and the attending physician has no evidence as to what the patient would desire, the physician should discuss the issue with the Office of the General Counsel. In these circumstances, if life-sustaining treatment could be initiated or continued, but, in the exercise of the physician's considered clinical judgment the initiation or continuance of such treatment would be ineffective, as defined above, an order withholding, withdrawing, or limiting such treatment, including a DNAR order, may be initiated.

9. The physician has no ethical obligation to provide life-sustaining interventions that, in the physician's medical judgment and experience, would be medically ineffective. In unusual cases, the patient or the patient's Health care Agent, Guardian or family member may disagree with the attending physician on the decision to withhold, withdraw or limit life-sustaining treatment. The patient or surrogate should be offered a second opinion. If this process is unsuccessful, the physician should then offer to transfer responsibility for the patient's care to another physician willing to provide the disputed intervention(s) either at the home institution or at another institution, and provide assistance in arranging such a transfer. All disputed cases of this nature should be discussed with General Counsel.

Documentation of DNAR Orders

The DNAR order should be entered into the order section of the patient's chart. A statement that the DNAR order has been written should be placed in the progress section. The DNAR Information Sheet should be completed with notes setting out the following:

• A summary of the staff discussion regarding the patient's condition and the reason and justification for the order.

• A statement regarding the patient's competence.

• A statement addressing the circumstances of the consent by the patient, if the patient is competent. However, if the patient is incompetent, the discussion and concurrence of the health care agent, guardian or family members, whichever applies, should be included in the statement.

• A statement of comfort measures to be taken, and any other care to be limited or withdrawn.

Patient’s Undergoing Interventional Procedures

A patient’s wish for withdrawing, withholding or limiting therapy including DNAR is not automatically suspended when the patient undergoes anesthetic care (including conscious sedation), an operation, radiation therapy or a special interventional procedure. It is incumbent upon the surgeon or interventionalist, the anesthesiologist (if involved) and the patient or that patient’s agent to meet and discuss the planned procedure, or anesthetic, and the patient’s or agent’s wishes. The patient or patient’s agent must then decide whether to totally suspend the DNAR Order, to suspend portions of the DNAR Order, or to maintain the DNAR Order in its entirety.

There should be documentation by the physician on the DNAR Order Sheet of what therapies, if any, are to be limited in the perioperative period, and also the duration of any changes in the DNAR Order. If there is no documentation of any limitation the existing DNAR Order shall be deemed to remain in effect.

When the surgeon, interventionist, anesthesiologist, or other provider of care believe the
proposed limitation of intervention decisions to be irreconcilable with his/her own moral views, then the surgeon or interventionist, anesthesiologist, or other provider of care should withdraw in a non-judgmental fashion from the proposed care. If withdrawal is not possible within the time frame necessary to prevent further morbidity or suffering, care must be provided by the surgeon, interventionist, anesthesiologist, or other provider of care with adherence to the patient’s directives, being mindful of the patient’s goals and values.

Correspondence to

Bradley J. Phillips, MD Critical Care Medicine CCM 2707 88 E. Newton St. Boston Medical Center Boston, MA 02118 Tel: (617) 638-6406 Fax: (617) 638-6452 Email: bjpmd2@aol.com