It is the policy of [the name of the dialysis unit] to respect the informed oral or written refusal of cardiopulmonary resuscitation (CPR) in the dialysis unit by patients with decision-making capacity or the health care agents for patients who lack decision-making capacity. In response to an informed refusal of CPR, [the name of the dialysis unit] will issue and honor a do-not-resuscitate (DNR) order for such patients.
II. Rationale for the Policy
CPR is not a successful therapy for most dialysis patients who undergo it. Patients who undergo and survive CPR may have major complications. Because dialysis patients already often bear considerable burdens as a result of dialysis and the frequent occurrence of co-morbid conditions, such as diabetes, congestive heart failure and peripheral vascular disease, many dialysis patients elect to limit the extent of life-prolonging medical care. Such limitations may include a decision to refuse CPR in the dialysis unit and request a DNR order. Honoring the decision of a patient with decision-making capacity (or the decision of a health care agent for a patient who lacks decision-making capacity) not to undergo CPR is ethically justified by the principle of respect for patient autonomy and legally justified by the doctrine of informed consent and the patientís right to self-determination. Furthermore, the performance of CPR on dialysis patients with significant co-morbid conditions who have an extremely poor prognosis with CPR violates the ethical principle of non-malfeasance.
Advance Directive An oral or preferably written statement by a patient with decision-making capacity expressing his/her preferences for a health care agent and/or for future medical care in the event he/she becomes unable to participate in medical decision-making. All 50 states have one or more laws or regulations recognizing written advance directives and the rights of patients to have their wishes respected. There are two types of written advance directives: a living will (an instruction directive in which the patient gives directions for future medical care in the event of particular medical conditions, such as a terminal illness or a persistent vegetative state); and a health care proxy (a proxy directive in which the patient designates a person to make decisions for him/her when the patient loses decision-making capacity). In some states, the health care proxy is referred to as a medical power of attorney or a durable power of attorney for health care. In some states, both instruction and proxy directives may be combined into one advance directive form. All advance directives must comply with applicable state procedural and substantive laws.
Attending Physician A licensed physician with staff privileges in the dialysis facility selected by or assigned to the patient who has primary responsibility for treatment of the patient. (In the case of dialysis patients, this physician is likely to be the nephrologist primarily assigned to the supervision of the patient's dialysis and related care.) If more than one physician shares the responsibility for care of the patient, any of those physicians may act as the attending physician under this policy.
Cardiopulmonary Resuscitation (CPR) A procedure performed to attempt to support and restore ventilation and circulation in a patient experiencing cardiac arrest (systole, ventricular fibrillation, or pulseless electrical activity) or respiratory arrest (cessation of respiratory effort). It includes establishment and maintenance of an airway, assisted ventilation, chest compressions, establishment of intravenous access, cardiac monitoring, administration of medications, defibrillation or other control of arrhythmias, and immediate care after resuscitation.
Decision-Making Capacity The capacity of a patient to 1) understand his/her medical condition; 2) appreciate the consequences (benefits and burdens) of various treatment options including non-treatment; 3) judge the relationship between the treatment options and his/her personal values, preferences and goals; 4) reason and deliberate about his/her options; and 5) communicate his/her decision in a meaningful manner. Assessment of decision-making capacity is a clinical judgment made by the patientís attending physician.
Do Not Resuscitate (DNR) Order An order written in an appropriate document (medical record, specially formulated advanced care directive, standardized form according to applicable state law or regulation, etc.) that indicates the patient's (or health care agentís) decision to refuse CPR in the event of cardiac or respiratory arrest in the dialysis unit. This order does not restrict the provision of standard measures in dialysis treatment such as fluid resuscitation for intradialytic hypotension, nor does it preclude other forms of care meant to provide comfort and to relieve suffering. A DNR order only becomes effective when the patient has experienced a cardiac or respiratory arrest.
Health Care Agent, Proxy, Surrogate, Guardian, Medical Power of Attorney, or Durable Power of Attorney for Health Care A person who, in accordance with applicable state laws, has been selected by a patient, or who, in accordance with applicable state laws, has been appointed, and has been given the authority to make informed health care decisions for the patient in the event the patient loses decision-making capacity. The appropriate terminology may vary from state to state, but the intent to allow an individual to pre-assign decision-making authority to another person is common among all such instruments. To the extent permitted by applicable state law, the health care agent may have the opportunity to be guided in his/her decision-making by prior knowledge of the patient's wishes through conversations and/or the stipulations in a written advance directive.
Living Will The living will, also known as an instruction directive, indicates a patientís wishes to be followed if he/she loses decision-making capacity. Wishes may refer to care in the event of particular medical conditions such as a terminal illness or a persistent vegetative state. The patient may indicate that he/she wishes under certain circumstances to have or continue treatments such as dialysis or CPR or to discontinue or refrain from such treatments.
Patients Without Decision-Making Capacity A patient who in accordance with the clinical judgment of the attending physician, clinical practice guidelines, and applicable state laws, has been declared to lack the capacity to: 1) understand his/her medical condition; 2) appreciate the consequences (benefits and burdens) of various treatment options including non-treatment; 3) judge the relationship between the treatment options and his/her personal values, preferences and goals; 4) reason and deliberate about his/her own options; and 5) communicate his/her decision in a meaningful manner.
IV. Statement of Principles
Addendum A - Advance Directive for a Do Not Resuscitate Order in the Dialysis Unit
PDF 68 KB
Addendum B - Recommendations for Advance Preparation for Death
PDF 133 KB
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