Correspondence

Overriding a Patient's Refusal of Treatment after an Iatrogenic Complication

N Engl J Med 1997; 337:1477November 13, 1997

Article

To the Editor:

Casarett and Ross (June 26 issue)1 ignore an important ethical principle that argues for resuscitation of a patient who has had an iatrogenic cardiopulmonary arrest — the principle of patient autonomy. The wishes of the patient were presumably followed in placing the initial do-not-resuscitate (DNR) order, which should have been the result of an informed decision-making process. DNR orders are best used to allow patients to make decisions about refusal of treatment for a foreseeable event.2 An iatrogenic arrest is not usually included in the range of events anticipated by patients when they ask for or agree to a DNR order, so they do not consent to its being withheld. Arguably, since an iatrogenic arrest is not foreseen, there is not true informed refusal of treatment, and the patient should be resuscitated.

The essay would argue that you should not perform the Heimlich maneuver on someone with a DNR order who chokes during a meal in a hospital bed.

Spencer A. Hall, M.D., J.D.
P.O. Box 13, Lincoln, NM 88338

2 References

1. 1

   Casarett D, Ross LF. Overriding a patient's refusal of treatment after an iatrogenic complication. N Engl J Med 1997;336:1908-1910
   Full Text | Web of Science | Medline

2. 2

   Veatch RM. Abandoning informed consent. Hastings Cent Rep 1995;25:5-12
   Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Dr. Hall contends that patients do not anticipate iatrogenic complications “when they ask for or agree to a DNR order.” We would argue that patients should not be expected to anticipate iatrogenic events and that the onus is on physicians to describe the wide range of situations in which cardiopulmonary arrest may occur. This explains why physicians may not know their patients' preferences regarding a common occurrence.1,2 Better communication between physicians and patients is important for DNR status in particular and end-of-life care in general. Dr. Hall is correct when he says that this situation arises because the process of informed consent surrounding DNR orders is inadequate. This ethical issue is, itself, iatrogenic.

Dr. Hall suggests that when a physician honors a patient's DNR status after an iatrogenic cardiac arrest the patient's autonomy may not be respected. We agree. However, the physician may also fail to respect the patient's autonomous wishes if cardiopulmonary resuscitation is performed. Therefore, we disagree that the DNR order should be overridden. When a patient's preferences regarding an iatrogenic cardiac arrest are not clear, the patient's consent to DNR status offers the best evidence of the patient's autonomous preference not to undergo this invasive intervention. Physicians should therefore respect the patient's DNR status, even when the cause of the arrest is iatrogenic.

David Casarett, M.D.
Lainie F. Ross, M.D., Ph.D.
University of Chicago, Chicago, IL 60637

2 References

1. 1

   Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients -- results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370-376
   Full Text | Web of Science | Medline

2. 2

   Bedell SE, Deitz DC, Leeman D, Delbanco TL. Incidence and characteristics of preventable cardiac arrests. JAMA 1991;265:2815-2820
   CrossRef | Web of Science | Medline