Good afternoon, everyone. Thank you so much for being here. Hopefully this will be a great session for you. I want to apologize at the get-go. I'm going to have to leave this session a little bit early because Delta Airlines moved my flight two hours earlier. So I have to sort of amscray and so I won't be able to stick around for the question and answer and discussion section. So I apologize for that. But if you have any questions or things you want to chat with me about, feel free to shoot me an email. I'm going to be talking about unilateral DNR and is it ever ethical? I have no disclosures. I do want to just briefly touch on I'll be using the term DNR in this talk because that's the term that we that we have. I actually in my own practice use DNAR, which is do not attempt resuscitation, and some folks use AND, allow natural death. The different nomenclature for the same concept, those are inpatient code status orders as opposed to upholster most, which is an outpatient order set. So DNR versus all other medical care. So I think it's really important to think about this. Right. So for all other medical care, the patient or representative needs to consent to or get permission for treatment. We often use implied consent. So, for example, for blood draws, physical exams, prescription medications, things like that. We assume that people agree to let us do those things. But people can always say, no, don't do that to me. And they always have a right to do that. Or surrogates can say, don't do that to my loved one. And they have a right to do that. But we often use implied consent for a whole host of things that we do in the ICU. Then there's informed consent where the patient or representative needs to understand what's being proposed and the reasonable alternatives, is able to make, to make, to reason through making a choice, appreciate the consequences of making a choice, and is able to make a choice and state it clearly. And those are the four criteria from Applebaum and Grizzo. And then there's written consent, which is generally required for invasive procedures. And many would argue that's more for protection of the institution than for the patient. But that's a whole other issue. Code status, by default, patients are full code unless there's an order to the contrary. So it's a default consent to treatment, which is really different than everything else we do. So patients have a right to be told what's being proposed and to the reasonable alternatives with sufficient information to allow them to understand the proposed treatment and alternatives to the extent that that patient wishes or that surrogate wishes. And they have the right to say, this is too much information for me. I don't want this much information and to make decisions with less information than we might think they should have. Patients have a right to decline to hear more information than they want. And they do not have a right to demand treatment that provider believes is not medically indicated. And we can talk more about that. But that's been well established by the Society of Critical Care Medicine since the 1980s with Marian Danis's excellent paper that came out then. So when we think about unilateral DNR, we can think about slightly different things. We can think about informed non-dissent, which is not actually a unilateral DNR. DNR without disclosure or DNR over patient or agent objection. So when we think about informed non-dissent, I don't have a lot of time to get into it. But it's been officially endorsed by SCCM and ATS. It's widely accepted. If you don't know what it is or if you'd like more information about it, then when SCCM releases the audio and slides from this conference in a few weeks, you should feel free to listen to our session earlier from today where we talked about that at some length. DNR without disclosure. So the provider orders DNR status but doesn't discuss that with the patient and family. There's no oversight. There's very wide agreement that that's ethically problematic and people shouldn't be doing that. So I'm not going to be discussing that today. But DNR over objection is what I'm really going to be focusing on. And what's the ethical justification? So this comes from the five organization policy statement. Patients have an interest in receiving care consistent with their values and preferences. However, clinicians have an interest in not being compelled to act against their best understanding of their professional obligations. And society has important interest in protecting individual rights, fostering clinician professionalism, and ensuring the fair allocation of medical resources. What I want to talk about a little bit, though, is critical care professionals as moral agents. So performing chest compressions when we feel that there's no point, and I'll put that in parentheses, leads to moral distress, job satisfaction, and burnout. It impacts the care on other patients. And particularly now when there's a real shortage of critical care professionals, this is something we need to really take seriously and think about. And I've thought a lot about this issue of critical care professionals as moral agents for a long time. And then yesterday, Erica Andrist, in a great presentation, I think summed it up in a way that I had never put into words, but did an amazing job. So I want to credit her with that. And what she said is this. If we just do whatever the family wants and discount our own moral agency, what we're doing is we're treating critical care professionals merely as a means to someone else's end. And one of the fundamental principles of Kantian ethics is never treat a person merely as a means to an end. And so when we do that, we're violating one of the very basic ethical tenets that has been accepted for literally hundreds of years. And it's really important to realize that. Well, is there agreement around this? So physicians actually seem to be split, and I talk about physicians in particular because most of the research has asked physicians what they think about this issue, as opposed to broader critical care team, which I think is unfortunate and a real shortcoming of the research, but that's where we are. So what we find is that most physicians support the ability to write a unilateral DNR, but many disagree. Ethicists are split. Courts have been split. But many professional organizations officially support DNR over patient or surrogate objection, including the American Medical Association, SCCM, ATS, ACCP, AACN, ESICM, big organizations, all in agreement that this can be appropriate. And many healthcare facilities have policies supporting unilateral DNR over patient or over surrogate and patient objection. But it's important to know your actual state law, particularly when you're developing your hospital policy. So a few states specifically allow unilateral DNR, and you can see that list up there. But four states actually specifically forbid unilateral DNR. So New York, Idaho, Minnesota, and Oklahoma. And the vast majority of states actually have no statutes on this topic. But it's important to understand what the laws are where you practice. When we look at Europe, it's a very different scenario. Multiple cases of unilateral DNR and withdrawal of life-prolonging care over family objection, particularly in England, but throughout Europe, courts fully support this practice. It's virtually unquestioned in Europe. We need to think about discrimination, though. So we may not decline to provide care based on patient race, ethnicity, religion, gender, et cetera. Gender identity is now an issue that the courts are trying to struggle with. We may not discriminate against patients based on disability due to the Americans with Disability Act. And some have argued that terminal illness or severe neurologic injuries are disabilities, and therefore we may not use that status as a justification for limiting care. However, that position is not widely accepted. Healthcare workers have a right to decline to participate in care that they deem inappropriate. We as healthcare in the U.S. have thought about this for a long time. So if, say, a nurse has a personal moral objection to abortion, then that staff member does not have to participate in procedures around abortion. But there are a lot of requirements around there. So that nurse needs to inform their leadership that they're not comfortable with that, and there needs to be other mechanisms so that in a location where abortion is legal, that the patient still has the ability to get that abortion. So we need some workarounds. Well, what about DNR status? So similarly, healthcare professionals can decline to participate in cardiopulmonary resuscitation or any procedure, even life-prolonging procedures, if they believe that those procedures are inappropriate. In those cases, healthcare professionals need to follow very specific procedures to ensure that the patient has an opportunity to find another professional willing to provide that requested care. And when we think about, like, the ER and the ICU in particular, because of the way we run, we have a very special obligation, right? So when patients come to us, not only is it a life-or-death situation, they're gravely ill, everyone's terrified, but they have no choice where they are, right? They usually come to us by ambulance, and they're just going to the closest facility or to the facility that can take them. They have no choice over who's their doctor or nurse, because whoever is on service or who's ever on shift that time, those are the people who take care of them. And if they say, well, I don't like this doctor, I want a different doctor, we say, sorry, this is the doctor that's on. And transferring to another facility is super hard. So we have extra layers of protection in the ICU that we may not need that same level in some other parts of the hospital, and certainly not in outpatient care. So when we think about futility versus inappropriate treatment, the five organizations came together and said, we're going to use the term futile only to mean circumstances where it's impossible to get the intended physiologic goal. So for example, the goal of CPR, the agreed upon goal is ROSC, right? Return of spontaneous circulation. That's the goal. So if you have a ruptured left ventricle, we know that CPR is never going to get you to ROSC. And so CPR is futile in the face of a ruptured left ventricle. But the vast majority of these cases, it's not that. We use the term potentially inappropriate rather than futile to describe treatments that have at least some chance of accomplishing the aside effect by the patient. But clinicians believe that competing ethical considerations justify not providing them. For example, a team may feel that CPR is inappropriate in a patient who's in, for example, persistent vegetative state. That's a values judgment. It's not a physiologic judgment because it's all based on what's the goal of care. We know that CPR can return spontaneous circulation. But what the team is saying is, yes, but in this patient, that's not an appropriate goal. The five organizations recommend a fair dispute resolution process, seven steps. Hopefully you're all familiar with this. Enlist expert consultation and continue negotiation. Give notice of the process. Obtain a second opinion. Review by an interdisciplinary hospital team, which may be an ethics committee or it may be a different committee. Offer the surrogates the opportunity to transfer to another institution. Inform them of the option of pursuing extramural appeal. That means going to court and trying to get a court order. And then implementing the decision of the resolution process. That takes time. And often decisions need to be made quickly. For example, if we believe that CPR is inappropriate in a patient, then making a code status order decision quickly is important because if that patient deteriorates in the next hour or two hours, we want to know what we're going to do. So we would consider that a time limited decision that can still be reviewed and reassessed, but an initial decision needs to be made. And so what the guidelines say is if a clinician has a high degree of certainty that requested treatment is outside accepted practice, they should refuse to provide that treatment and endeavor to achieve as much procedural oversight as possible. So the SECM ethics committee was kind of uncomfortable with that because it leaves things wide open. Because some people may feel that certain things are inappropriate and others other things, and it leads to a lot of disparate care. So particularly in emergency situations, but then sort of more globally, the ethics committee felt that some more guidance would be helpful. And so what those guidelines came out and said was, if there's no reasonable expectation that the patient will improve sufficiently to survive outside the acute care setting, or there's no reasonable expectation that the patient's neurologic function will improve sufficiently to allow patients to receive the benefit of treatment, then you can consider life-prolonging interventions and ICU interventions to be inappropriate. But it's really important to realize that what SECM said is this is not obligatory. So this is not saying to people, when patients meet these criteria, you shouldn't admit them to your ICU or you shouldn't do CPR. What they're saying is, if you feel like it's not appropriate to do CPR or admit patients to your ICU, these are the things that may help you think about that. And these are what we think would make sense as a baseline criteria. But it's also not exhaustive, which means that there are going to be some cases that don't fit either of those, but still the team feels that those interventions would be inappropriate. So in summary, unilateral DNR is ethically justifiable, but remains controversial. And the ethical justification is really around this concept of we are also moral agents. We, the ICU team. And that what we believe is within or outside our professional obligations and what we are comfortable with really matters. Because performing chest compressions on a patient that you feel like this is not appropriate is incredibly difficult for us. And it leaves lasting scars on lots of ICU team members. And that has moral weight. There's broad agreement supporting unilateral DNR among professional organizations. However, many individual professionals disagree. More controversial in the general public and courts. Important to know your state statutes. If there's time, follow the seven step process. And if not, if it meets the criteria as CCM put out, and also answering the questions that go along with the seven step process that the five organizations put out, then making decisions quickly may be necessary and can be appropriate. And with that, I will stop and hand over the podium. Thanks very much. Thank you.

unilateral DNR orders

ethical complexities

moral agency

healthcare professionals

dispute resolution process