Beyond autonomy--physicians' refusal to use life-prolonging extracorporeal membrane oxygenation

From Bridge to Destination? Ethical Considerations Related to Withdrawal of ECMO Support over the Objections of Capacitated Patients

Extracorporeal membrane oxygenation (ECMO) is typically viewed as a time-limited intervention-a bridge to recovery or transplant-not a destination therapy. However, some patients with decision-making capacity request continued ECMO support despite a poor prognosis for recovery and lack of viability as a transplant candidate. In response, critical care teams have asked for guidance regarding the ethical permissibility of unilateral withdrawal over the objections of a capacitated patient. In this article, we evaluate several ethical arguments that have been made in favor of withdrawal, including distributive justice, quality of life, patients' rights, professional integrity, and the Equivalence Thesis. We find that existing justifications for unilateral withdrawal of ECMO support in capacitated patients are problematic, which leads us to conclude that either: (1) additional ethical arguments are necessary to defend this approach or (2) the claim that it is not appropriate to use ECMO as a destination therapy should be questioned.

Factors Associated With Provision of Nonbeneficial Surgery: A National Survey of Surgeons

OBJECTIVE

We tested the association of systems factors with the surgeon's likelihood of offering surgical intervention for older adults with life-limiting acute surgical conditions.

BACKGROUND

Use of surgical treatments in the last year of life is frequent. Improved risk prediction and clinician communication are solutions proposed to improve serious illness care, yet systems factors may also drive receipt of nonbeneficial treatment.

METHODS

We mailed a national survey to 5200 surgeons randomly selected from the American College of Surgeons database comprised of a clinical vignette describing a seriously ill older adult with an acute surgical condition, which utilized a 2×2 factorial design to assess patient and systems factors on receipt of surgical treatment to surgeons.

RESULTS

Two thousand one hundred sixty-one surgeons responded for a weighted response rate of 53%. For an 87-year-old patient with fulminant colitis and advanced dementia or stage IV lung cancer, 40% of surgeons were inclined to offer an operation to remove the patient's colon while 60% were inclined to offer comfort-focused care only. Surgeons were more likely to offer surgery when an operating room was readily available (odds ratio: 4.05, P <0.001) and the family requests "do everything" (odds ratio: 2.18, P <0.001).

CONCLUSIONS

Factors outside the surgeon's control contribute to nonbeneficial surgery, consistent with our model of clinical momentum. Further characterization of the systems in which these decisions occur might expose novel strategies to improve serious illness care for older patients and their families.

Decision-Making, Ethics, and End-of-Life Care in Pediatric Extracorporeal Membrane Oxygenation: A Comprehensive Narrative Review

OBJECTIVES

Pediatric extracorporeal membrane oxygenation is associated with significant morbidity and mortality. We sought to summarize literature on communication and decision-making, end-of-life care, and ethical issues to identify recommended approaches and highlight knowledge gaps.

DATA SOURCES

PubMed, Embase, Web of Science, and Cochrane Library.

STUDY SELECTION

We reviewed published articles (1972-2020) which examined three pediatric extracorporeal membrane oxygenation domains: 1) decision-making or communication between clinicians and patients/families, 2) ethical issues, or 3) end-of-life care.

DATA EXTRACTION

Two reviewers independently assessed eligibility using Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology.

DATA SYNTHESIS

Of 2,581 publications screened, we identified one systematic review and 35 descriptive studies. No practical guides exist for communication and decision-making in pediatric extracorporeal membrane oxygenation. Conversation principles and parent/clinician perspectives are described. Ethical issues related to consent, initiation, discontinuation, resource allocation, and research. No patient-level synthesis of ethical issues or end-of-life care in pediatric extracorporeal membrane oxygenation was identified.

CONCLUSIONS

Despite numerous ethical issues reported surrounding pediatric extracorporeal membrane oxygenation, we found limited patient-level research and no practical guides for communicating with families or managing extracorporeal membrane oxygenation discontinuation.

Ethical challenges of adult ECMO

The use of extracorporeal membrane oxygenation (ECMO) is expanding rapidly, and as more centres streamline their management policies, the bioethics literature on ECMO has been highlighting the ethical challenges of using an expensive, resource-intensive technology including its eligibility, duration of support, cost-effectiveness and societal repercussions. The absence of high-quality studies on long-term outcomes of ECMO survivors leads to multiple ethical problems involving patient autonomy, beneficence and clinical wisdom pertaining to its initiation, maintenance and termination. This article reviews some of the ethical challenges that affect decision-making during ECMO therapy and suggests an ethical framework that may help the treating team deal with such conundrums, when the patient does not recover despite being on ECMO.

Watching Brian Die: The Rhetoric and Reality of Informed Consent

Two years ago, my brother-in-law was injured in a catastrophic industrial accident, which left him with second and third degree burns over 95 percent of his body. Writing both as a family member and as a sociologist, I analyse how his doctors increased their decision-making authority at the expense of informed consent, explore why they did so, and discuss the consequences for families when informed consent is not obtained. I also discuss the difficulties of achieving informed consent when family members have conflicting views on treatment. The conclusions use this story to reflect on the problems of implementing informed consent in clinical practice and on what these problems tell us about US doctors’ continuing power and clinical autonomy.

Double trouble: should double embryo transfer be banned?

What role should legislation or policy play in avoiding the complications of in-vitro fertilization? In this article, we focus on single versus double embryo transfer, and assess three arguments in favour of mandatory single embryo transfer: risks to the mother, risks to resultant children, and costs to society. We highlight significant ethical concerns about each of these. Reproductive autonomy and non-paternalism are strong enough to outweigh the health concerns for the woman. Complications due to non-identity cast doubt on the extent to which children are harmed. Twinning may offer an overall benefit rather than burden to society. Finally, including the future health costs for children (not yet born) in reproductive policy is inconsistent with other decisions. We conclude that mandatory single embryo transfer is not justified and that a number of countries should reconsider their current embryo transfer policy.

Justice and NHS dental treatment--is injustice rife in NHS dentistry?

In this article the issue of injustice in NHS dental care is examined using the philosophical principles of non-ideal theory. The causes for this injustice in this context are examined as well as how injustice may be perpetuated within the NHS dental system. The focus upon targets that the current system supports contributes in shifting the focus of healthcare provision from being patient-centred to that of financial gain. This leads to a drop in quality of care and to dissatisfaction within the dental workforce. This article aims to examine this perversity and how this further contributes to injustice.

Decision-making in stem cell trials for spinal cord injury: the role of networks and peers

AIMS

The purpose of this study was to characterize the self-perceived role of professionals and personal caregivers in decision-making about participation in stem cell clinical trials by individuals in early post-spinal cord injury time-points.

MATERIALS & METHODS

Data were obtained from focus groups and semi-structured individual interviews from two networks: healthcare professionals (e.g., physicians, allied healthcare workers) and personal contacts (family and friends). We transcribed audio-recorded data in extenso and analyzed transcripts using the qualitative method of constant comparison.

RESULTS

Results from more than 60 h of data suggest that adequate decision support is difficult to achieve for individuals during the subacute phase of injury. Three major obstacles prevent this goal: the personal dimensions of risk; limited insights into the pathophysiology and recovery process; and deference of each network to the other.

CONCLUSION

The data suggest that novel strategies for decision-making processes, such as those involving peer support, are needed to enrich the knowledge base of all stakeholders. The results further underscore the importance of the role that both the academic and private sector play in ensuring the protection of human subjects in these trials.

Withholding and withdrawing dialysis in the intensive care unit: benefits derived from consulting the renal physicians association/american society of nephrology clinical practice guideline, shared decision-making in the appropriate initiation of and withdrawal from dialysis

Despite advances in the technology of dialysis, mortality in patients who develop acute renal failure remains high. Scoring systems have been developed to improve the ability to define prognosis in seriously ill patients with acute renal failure but predicting outcomes for individual patients is uncertain. Decisions to withhold or withdraw dialysis in seriously ill patients are difficult for patients, families, and health care providers. The clinical practice guideline, Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis, provides evidence-based recommendations to aid nephrologists in discussions and the process of medical decision-making about starting and stopping dialysis. Estimating prognosis and addressing the issues of advance directives and patient and family preferences through the process of shared decision-making can clarify appropriate strategies for clinical management and interventions. Time-limited trials of dialysis may be an invaluable tool in this process. Increasing nephrologists' awareness of the guideline may facilitate decision-making around the issues of withholding and withdrawing dialysis in part by clarifying patients and situations in which it may be appropriate to withhold or withdraw dialysis.

Extracorporeal membrane oxygenation for support of children after hematopoietic stem cell transplantation: the Extracorporeal Life Support Organization experience

PURPOSE

Extracorporeal membrane oxygenation (ECMO) is a means of respiratory and hemodynamic support for patients failing conventional therapies. Children requiring hematopoietic stem cell transplantation who develop complications during therapy may require ECMO. Such patients pose medical and ethical challenges for clinicians considering initiation of ECMO. The authors review the outcomes of these patients and propose recommendations.

METHODS

The Extracorporeal Life Support Organization Registry was queried for all patients younger than 18 years with an International Classification of Diseases, Ninth Revision, or Current Procedural Terminology code related to bone or stem cell transplant.

RESULTS

Nineteen children in the registry met inclusion criteria. The median age was 9.6 years (7 months to 17.5 years). Initiation of ECMO was for pulmonary support (n = 17), cardiac support (n = 1), or cardiopulmonary resuscitation (n = 1). The median duration of ECMO support was 5.1 days (range, 30 hours to 42 days). Pulmonary infections included 3 parainfluenza, 2 Pneumocystis carinii, 1 influenza A, and 1 respiratory syncytial virus. Overall, 15 (79%) died during their ECMO run, whereas only 4 (21%) survived to come off ECMO. Furthermore, of those who survived their ECMO run, only one patient survived to discharge from the hospital. Risk factors for death on ECMO include development of renal complications and development of multiorgan dysfunction.

CONCLUSION

Patients who require ECMO for cardiopulmonary support after hematopoietic stem cell transplantation have a poor prognosis. Clinicians must be cautious in presenting this option to parents and present them with appropriate expectations in this high-risk population.

Extracorporeal membrane oxygenation after stem cell transplant: clinical decision-making in the absence of evidence

OBJECTIVE

To discuss the ethical dilemmas that arise in considering innovative therapies for critically ill children when there is little data to support their use.

DESIGN

Case report of a 13-yr-old patient after autologous peripheral blood stem cell transplant for stage III neuroblastoma with sepsis and hemodynamic instability who survived to discharge after a 6-day course of extracorporeal membrane oxygenation (ECMO) support. The case serves as a source of discussion of the following: the use of available data in deciding to proceed with an unproved therapy, the approach to conversations to obtain informed consent, and the need for institutional oversight and hypothesis-driven data collection to advance pediatric critical care.

SETTING

Pediatric intensive care unit at a university hospital.

PATIENT

One adolescent with stage III neuroblastoma.

RESULTS

Despite a lack of data to support the use of ECMO in a neutropenic oncology patient after autologous peripheral blood stem cell transplant, our patient had clinical features that suggested he was a reasonable ECMO candidate. His family gave informed consent to use ECMO and he survived. It is ethical to consider and use innovative therapies when patient characteristics are suggestive that the therapy may be successful even in the absence of evidence. This requires physicians' attention to the best interest of the patient and should occur in the setting of informed consent and rigorous data collection.

CONCLUSIONS

The boundaries among standard therapy, innovative therapy, and research can be quite fluid. This case illustrates the ethical imperative to consider therapies that may be appropriate for a critically ill child even without evidence predictive of success, to have entry criteria and treatment protocols for such therapies, and to collect data from such experiences to advance the standard of care.

End-of-life after birth: death and dying in a neonatal intensive care unit

OBJECTIVE

In canonical modern bioethics, withholding and withdrawing medical interventions for dying patients are considered morally equivalent. However, electing not to administer cardiopulmonary resuscitation (CPR) struck us as easily distinguishable from withdrawing mechanical ventilation. Moreover, withdrawing mechanical ventilation from a moribund infant "feels" different from withdrawing mechanical ventilation from a hemodynamically stable child with a severe neurologic insult. Most previous descriptions of withdrawing and withholding intervention in the neonatal intensive care unit (NICU) have blurred many of these distinctions. We hypothesized that clarifying them would more accurately portray the process of end-of-life decision-making in the NICU.

METHODS

We reviewed the charts of all newborn infants who had birth weight >400 g and died in our hospital in 1988, 1993, and 1998 and extracted potential ethical issues (resuscitation, withdrawal, withholding, CPR, do-not-resuscitate orders, neurologic prognosis, ethics consult) surrounding each infant's death.

RESULTS

Using traditional definitions, roughly half of all deaths in our NICU in 1993 and 1998 were associated with "withholding or withdrawing." In addition, by 1998, >40% of our NICU deaths could be labeled "active withdrawal," reflecting the extubation of infants regardless of their physiologic instability. This practice is growing over time. However, 2 important conclusions arise from our more richly elaborated descriptions of death in the NICU. First, when CPR was withheld, it most commonly occurred in the context of moribund infants who were already receiving ventilation and dopamine. Physiologically stable infants who were removed from mechanical ventilation for quality-of-life reasons accounted for only 3% of NICU deaths in 1988, 16% of NICU deaths in 1993, and 13% of NICU deaths in 1998. Moreover, virtually none of these active withdrawals took place in premature infants. Second, by 1998 infants, who died without CPR almost always had mechanical ventilation withdrawn. Finally, the median and average day of death for 100 nonsurvivors who received full intervention did not differ significantly from the 78 nonsurvivors for whom intervention was withheld.

CONCLUSIONS

In our unit, a greater and greater percentage of doomed infants die without ever receiving chest compressions or epinephrine boluses. Rather, we have adopted a nuanced approach to withdrawing/withholding NICU intervention, providing what we hope is a humane approach to end-of-life decisions for doomed NICU infants. We suggest that ethical descriptions that reflect these nuances, distinguishing between withholding and withdrawing interventions from physiologically moribund infants or physiologically stable infants with morbid neurologic prognoses, provide a more accurate reflection of the circumstances of dying in the NICU.

Should we refuse requests for complementary therapies?

Health care providers sometimes receive requests from patients or families for complementary therapies. When should they accede to such requests, and when should they refuse them? This is not a problem peculiar to complementary therapies. It arises whenever patients or families request conventional therapies which health care professionals judge problematic in the circumstances. What follows is a set of rationalized recommendations about when health care professionals should and should not honour requests for therapies, whether they be conventional or complementary.

Futility considerations in the neonatal intensive care unit

The purpose of this article is to summarize and comment on the history of medical decision making in the neonatal intensive care nursery, emphasizing considerations of futility. Several epochs will be described, with shifting roles of health care providers, the infant's family, and proxies for society at large. Futility has been an issue in the intensive care of newborn infants throughout the last 35 years. Long before the Baby Doe regulations and the formation of ethics committees, neonatologists tried to determine which care measures were indicated. Given the frequency of severe malformations, birth asphyxia, and extreme prematurity, it has been a common event for the responsible physician to ask himself: will this treatment be beneficial or merely futile? As the therapeutic armamentarium became more powerful and complex, the choices from among a possible array of interventions became increasingly difficult. The autonomy of parents as decision makers was increasingly affirmed. In the 1980s, the federal government, the courts, and frequent malpractice suits set boundaries on medical decision making. In the 1990s, third party payors became increasingly assertive in limiting resource expenditure. These legal and societal mandates are frequently at variance with one another. Thus the issue of medical futility, as it applies to neonates in the United States, must be considered unresolved.

Is the patient's right to die evolving into a duty to die?: Medical decision making and ethical evaluations in health care

When patient or family requests for continued life-sustaining treatments conflict with doctor recommendations, different conclusions as to what is beneficial for the patient may arise. Past practices usually accepted patient or family requests based on the principle of autonomy or that the doctor's primary responsibility is to the individual patient. Many patients die in intensive care units after doctors forego life-prolonging interventions. Health care changes and cost containment have led to a change in the classical ethical model of the patient-doctor relationship such that concerns for societal requirements increasingly overrule those for individual patient needs. The ability to keep patients alive with little likelihood of recovery and the recognition of escalating health costs have led to calls for the needs of society and distributive justice to be taken into account. A tendency to justify a duty to die for these patients has arisen. Recent legal decisions in cases with conflicts between families and health care providers and institutions over foregoing life-sustaining therapies have decided for the families against doctors and hospitals, compelling institutions and their staff to act contrary to their ethical views. Value judgments of doctors are sometimes confused with medical indications for therapy. Doctors have defined therapies as futile or non-beneficial based on their own values and even withdrawn life-sustaining treatments without patient or family input. In some cases, the right to die is leading to the duty to die even against patient or surrogate wishes. Such observations indicate the need for rigorous analyses of medical decision making in this context and for ethical evaluations in health care in general.

Resource consumption and the extent of futile care among patients in a pediatric intensive care unit setting

OBJECTIVES

To estimate resource consumption and the extent of futile care among patients admitted to the pediatric intensive care unit (PICU).

STUDY DESIGN

A prospective cohort study of 353 consecutive admissions followed for 1334 patient-days during the PICU stay at the Texas Children's Hospital in Houston, Texas. Participants were 353 children and adolescents who were hospitalized in the PICU during September and October 1993. Three broad operational definitions of futility were developed to capture the maximum extent of resource consumption related to medical futility. Definition 1 (imminent demise futility) was developed by an objective, validated, severity of illness measure (Pediatric Risk of Mortality Score) to identify patients with high mortality risks. Definition 2 (lethal condition futility) was used to identify patients in the PICU whose long-term survival was unlikely. Definition 3 (qualitative futility) was used to identify patients with high morbidity. Resource consumption was measured according to the number of patient-days in the PICU and the Therapeutic Intervention Scoring System.

RESULTS

Twenty-three (6.5%) patients representing 36 (2.7%) patient-days met at least one of the definitions of medical futility for some of the days when they were in the PICU. None of the patient-days that met any of the definitions of medical futility were associated with high resource consumption compared with non-futile care patient-days.

CONCLUSIONS

Despite our use of broad definitions of medical futility, relatively small amounts of resources were used in futile PICU care. This suggests that attempts to reduce resource consumption in the PICU by focusing on medical futility are unlikely to be successful.

Probability of survival after prolonged extracorporeal membrane oxygenation in pediatric patients with acute respiratory failure. Extracorporeal Life Support Organization

OBJECTIVE

Extracorporeal membrane oxygenation (ECMO) has been used with increasing frequency for respiratory failure that is unresponsive to conventional therapy. We examined the relationship between duration of ECMO and outcome to understand whether prolonged ECMO (duration of the procedure for > 14 days) was more commonly associated with futile therapy or eventual recovery.

DESIGN

A cohort study of all patients reported to the Pediatric ECMO Registry for Acute Respiratory Failure of the Extracorporeal Life Support Organization.

SETTING

Tertiary hospitals (n = 83) capable of providing extracorporeal support for pediatric patients.

PATIENTS

Children (n = 382) between the ages of 1 wk and 18 yrs of age with severe respiratory failure.

INTERVENTIONS

Extracorporeal membrane oxygenation.

MEASUREMENTS AND MAIN RESULTS

The death or live hospital discharge of ECMO-treated patients, together with the post-ECMO mechanical ventilation course, were examined as a function of duration of ECMO and of pre-ECMO respiratory status. The occurrence of complications and the causes of death were also noted. The criteria used to initiate ECMO, as well as the determination of the futility of further ECMO, were determined by local practice at individual centers. There were 382 patients treated with ECMO, of whom 184 (48%) survived. The proportional survival in the patients treated for the longest duration was similar to the overall group. The cause of death was given for 168 patients: 32 neurologic deaths; nine deaths due to ECMO complications; and 30 deaths due to nonpulmonary organ failure. There were 97 deaths due to elective ECMO termination; 80 of these deaths occurred after the determination of the futility of anticipating pulmonary recovery. The latter deaths occurred at widely varying durations of ECMO, with a median of 282 hrs. However, at that same duration, 47 eventual survivors (26% of all survivors) continued to receive ECMO. By discriminant analysis, the survival rate was independently related (r2 = .18; p < .0001) to peak ventilator inspiratory pressure before ECMO and duration of intubation before ECMO, patient age, and the occurrence of several complications.

CONCLUSIONS

While the survival rate in pediatric patients receiving ECMO appears related to the severity of lung disease and to the occurrence of ECMO complications, the survival rate in patients treated with ECMO courses of > 2 wks was similar to the survival rate of patients treated for shorter periods of time. ECMO was terminated in some patients for pulmonary futility at durations of ECMO associated with survival in substantial numbers of patients in whom ECMO was continued.

Futility and the common cold. How requests for antibiotics can illuminate care at the end of life

The dominant approach to futility in medicine assumes that the probability and utility of medical interventions may be separated to provide a quantitative (probabilistic) definition of futility. This assumption is not only misleading but also responsible for much of the confusion that futility has engendered in medical discussions. The divorce of utility from probability is the opposite of how clinicians reason: an improbable intervention looks different if it is cheap, easy, and without morbidity than if it is technology intensive, expensive, and likely to involve great pain and suffering. Futility is how physicians describe the sense of being compelled to proceed with resource intensive care for marginal benefits. Outside the intensive care unit, physicians weigh and sometimes reject patient requests without the need to invoke futility. By examining the ways that physicians can legitimately evaluate patient requests, we can show that appeals to futility are both unnecessary and counterproductive. In cases where such appeals are unavoidable, the outpatient model suggests a process to adjudicate the competing claims of patient autonomy and physician responsibility.

Judging medical futility: an ethical analysis of medical power and responsibility

In situations where experience shows that a particular intervention will not benefit a patient, common sense seems to suggest that the intervention should not be used. Yet it is precisely in these situations that a peculiar ethic begins to operate, an ethic that Eddy calls “the criterion of potential benefit.” According to this ethic, “a treatment is appropriate if itmighthavesomebenefit.” Thus, the various maxims learned in medical school instruct physicians that “‘an error of commission is to be preferred to an error of omission,’ or ‘when in doubt, cut it out’ or ‘if but one patient is helped, then the treatment is worthwhile.’”

The limits of proxy decision making: overtreatment

Traditionally, surrogates have been involved principally in making decisions about life-sustaining treatment for incompetent individuals. Today, surrogates are increasingly called upon to make everyday medical decisions for patients who are incompetent because they are demented. Some of the potential perils of proxy decision making under these circumstances have been identified, including the lack of concordance between patients and their proxies, demands by proxies for technically futile therapy, and actual abuse of patients. We found a significant number of cases in which healthcare providers at a long-term care facility came into conflict with surrogates because the treatment desired by the surrogate was viewed as excessively burdensome when evaluated by an experienced team of nurses, physicians, and social workers. Neither a court-appointed guardian nor an Institutional ethics committee were likely to be able to resolve these conflicts because of lack of clarity about what constitutes the best Interest of Impaired nursing home patients. The following case illustrates this increasingly common conflict.

Bargaining about futility

What I propose in this article is application of existing dispute resolution practices that take place outside the courtroom to the negotiating that takes place between health providers and families when they try to reach agreement about the limits of medical care that arguably is futile. Specifically, I focus on a bargaining paradigm that is associated with divorce proceedings, and suggest how this paradigm is at work in the conflict about futile treatment. At issue are not the well-publicized aspects of high profile cases, but the rather unpublicized bargaining that goes no further than the clinical setting.

Physicians and families who disagree about the futility of medical treatments frequently engage in give-and-take exchanges about whether to start disputed treatments, about what period of time might comprise a reasonable trial period if a treatment is to be administered, and about when and how to transfer a patient to another facility if the dispute cannot be resolved.

Ethical issues in the pediatric intensive care unit

Advanced technology and better scientific understanding of mechanisms of disease now permit intensive care personnel to extend life beyond what some patients and families consider reasonable, leading, in part, to the "patients' rights" movement and the articulation of legal and moral guidelines for foregoing life support. In the case of pediatrics, commentaries on a few of the topics that have arisen most frequently or have provided the greatest challenge in the authors' experience are provided.

Long-term care facility policies on life-sustaining treatments and advance directives in Canada

OBJECTIVE

To describe the prevalence and content of long-term care facility policies regarding the use of life-sustaining treatments (cardiopulmonary resuscitation (CPR), artificial hydration and nutrition, dialysis, antibiotics for life-threatening infections, transfer to acute care hospital) and advance directives in Canada.

DESIGN

Cross-sectional mailed survey.

SETTING

Canadian long-term care facilities with 25 beds or more listed in the 1991-92 Directory of Long Term Care Centres in Canada. Institutions listed as, "general hospitals," "psychiatric hospitals," "children's treatment centres," "group homes," or as purely residential facilities were excluded.

PARTICIPANTS

Chief Executive Officers or their designates.

MAIN OUTCOME MEASURES

Respondents' self-reports regarding the existence of life-sustaining treatment or advance directive policies and content analysis of the policies themselves.

RESULTS

Of 1472 long-term care facilities, 1021 (69%) responded. Of these, 344 (34%) institutions had 397 policies regarding the use of life-sustaining treatments or advance directives. Three hundred twenty facilities (31%) had 349 do-not-resuscitate (DNR) policies (40% on CPR alone and 60% on CPR plus other life-sustaining treatments). Seventeen institutions (2%) each had one policy addressing life-sustaining treatments other than CPR, and 31 institutions (3%) each had one policy addressing advance directives. Of the 397 policies, 171 (43%) required routine discussion with all patients, 156 (39%) mentioned futility, 331 (83%) indicated that the competent patient had the right to make a decision about life-sustaining treatment, 265 (67%) indicated that the family of the incompetent patient had this right, 27 policies (7%) mentioned conflict resolution, 378 (95%) had an explicit requirement for recording the decision, 10 (3%) required explicit communication of the decision to the competent patient, 10 (3%) required such communication to the family of the incompetent patient, 260 (66%) required updating of the decision, and 213 (54%) mentioned rescinding or changing the decision.

CONCLUSIONS

Only one-third of Canadian long-term care facilities have do-not-resuscitate policies, and even fewer have policies on advance directives or life-sustaining treatments other than CPR. The policies themselves could be improved by encouraging routine advance discussions, scrutinizing the use of the futility standard, stipulating procedures for conflict resolution, and explicitly requiring communication of the decision to competent patients or substitute decision makers of incompetent patients.