• © 2001 by American Society of Clinical Oncology

Discussing Do-Not-Resuscitate Status: Furthering the Discourse

To the Editor:

We read with great interest von Gunten’s article addressing the art of do-not-resuscitate discussions.¹ von Gunten’s discourse nicely illustrates the essential elements of a successful discussion on resuscitation status. By successful, we would mean a discussion that adequately conveys pertinent medical information to the patient and/or family, provides realistic expectations and goals of care, and allows enough time for the patient or family to assimilate this information so as to make a cogent end-of-life decision. von Gunten has put in concrete terms those factors that facilitate a discussion; namely, an appropriate setting, empathy from the physician, asking open-ended questions, determining patient understanding, and providing sufficient information in a caring manner. This is an excellent model for instructing physicians-in-training in the art of end-of-life discussions.

There are additional complexities involved that should be discussed. von Gunten touches briefly on the issue of patients who persist in their request for resuscitation despite appropriate discussion as outlined in his article. Resuscitation is not a suitable option for all patients, and if not, is it proper to discuss this procedure for patients in whom it is not indicated? Patients with acute, reversible medical conditions should have the prerogative of resuscitation. Patients dying of progressive malignancies for whom there is no expectation of benefit should not be subject to futile procedures. These patients will not achieve significant survival benefit from cardiopulmonary resuscitation.² Physicians are forced to violate the principle of “Do No Harm” and their own conscience when patients are unrelenting in their requests for resuscitation despite its futility. Certainly, dying and end-of-life decisions should be discussed in these situations, but should resuscitation be offered?³

There are cultural differences that alter end-of-life discussions. African-American physicians and patients are more likely than Caucasians to request artificial feeding, mechanical ventilation, or cardiopulmonary resuscitation if the patient is in a persistent vegetative state or is terminally ill.⁴ The Islamic perspective on do-not-resuscitate orders has been described and is complex.⁵ A do-not-resuscitate order is consistent with the tenets of Islam. The withdrawal of support in the setting of a persistent vegetative state is less clear, as Islam requires that no life be taken and does not formally recognize brain death as death.⁶

von Gunten’s presentation involved a patient with progressive malignancy, a situation about which most physicians would agree resuscitation is not appropriate, and a situation in which the trajectory of disease is predicted with relative accuracy. Terminally ill patients whose disease course entails periods of severe exacerbation followed by plateaus, as occurs in congestive heart failure, have distinctly different views. Congestive heart failure patients frequently have a significantly different preference from the treating physicians. Patients also change their minds regarding resuscitation during stable periods.⁷

We greatly appreciate von Gunten’s sensible and empathic approach to discussions of resuscitation status, but we do wish to point out that even a sensible, compassionate physician may encounter significant challenges regarding resuscitation. These challenges often transcend the physician’s ability to engage in a discourse centered on end-of-life decisions. A different approach will be necessary when faced with cultural and ethnic differences and nonmalignant terminal illnesses. A clear policy is necessary to resolve differences centered on medical futility.