History of DNR and cost of end-oflife care / John

The objective of this LO is to gain some perspective on our thoughts about the donot-resuscitate order, or DNR. Mrs. Bocharovs decline in health is complicated by
our and her familys confusion about what she wants us to do if shes going to die.
On the one hand, her family didnt even want a pericardiocentesis. On the other
hand, she asks that everything is done to keep her alive because shes not ready
to die tonight. A few salient questions arise. Is she sure? What does she consider
dying? Why havent previous providers talked about this? Why didnt we talk to her
about it earlier? Why hasnt her family talked about this? Has this always been what
shes wanted? Does she even know what everything might entail?
Lets redirect our regretful energies toward deepening our understanding of DNR
historically. After that, well briefly discuss the costs of end-of-life care.

The beginning of DNR:

backlash against CPR
When CPR was first invented in the US in
the early 1960s for patients in surgery,
especially those facing anesthesia-induced
cardiac arrest. Its remarkable simplicity
facilitated its spread throughout and
beyond the hospital, allowing laypeople
and healthcare workers alike to become
certified in basic life support.
However, by the late 1960s, cases of
terminally ill patients who received
repeated CPR only to prolong an agonizing
death persuaded healthcare workers to
refuse to perform a full resuscitation. At
first, there was no formal way of this refusal. Hospitals might put, for example, a
purple dot on the patients chart as a concealed indication that this person was
DNR. This informal and completely healthcare-driven decision about who would
receive potentially life-saving treatment, understandably, freaked people out. By the
early 1970s, orders to not resuscitateDNRevolved into a more formal process
with ample documentation and communication between patients, healthcare
workers, and other relevant persons.
When DNR was solidified as a formalized right for patients across the country,
Western bioethicists were poppin bottles. Western bioethicists in the 70s and 80s
loved this idea called patient autonomy, which meant that the patients wishes
have priority over the wishes of professionals and can refuse life-sustaining
treatment if they want to. These liberal Western bioethi cal principles are the

foundation for todays advance directives in general (see

U4C3_Neil_AdvanceDirectives).
At the same time, the judicial system was all over this because they believe that we
need laws for a functioning society. Generally, court cases confirmed that patients
have the right, based on interpretations of common law and the constitution, to
refuse medical treatment, including CPR. This may seem obvious, but in the eyes of
the law, we need to balance an individuals right to do what they want with their
body with the states interest in keeping that individual alive.
Heres a story. In 1975, a 21-year-old woman named Karen Ann
Quinlan became comatose after taking alcohol and tranquilizer
pills. An ambulance brought her to the hospital in the middle of
the night. She had to be put on a respirator because she couldnt
breathe on her own. Over the next few months, she deteriorated
and everyone agreed she was in a persistent vegetative state.
Her parents kept a close eye on her health and, in accordance
with their Catholic teachings, decided she could be removed from
the respirator and other mechanisms keeping her alive.
Unfortunately, her doctors, afraid of a retaliatory malpractice
suit, did not want to take her off the treatment. Little did they
know, this was America, and that they would be sued anyway, for trying to keep Ms
Quinlan on treatment.
The court case was, according to me, insane, and everyone pulled out all the stops
(excuse my irreverence). One judge said cit ed the 8 th amendment, saying that
keeping her alive was cruel and unusual punishment. Someone else said that
removing the respirator would be homicide. The court eventually ruled that they
could remove all the life-sustaining devices based on the idea that sometimes
individual rights could supersede the interest of the state, and the Quinlan case
became a landmark case in the right to die debate in the US.
(Miss Quinlans family actually didnt remove her feeding tube, just the respirator,
and she lived for 9 more years, dying in 1985 after going from 105 to 60 pounds.)

The situation with DNR today

The advent of CPR and making withholding treatment into an orderdo not attempt
to resuscitate me, pleasehas turned resuscitation into the norm; we need to optout of treatment (CPR). You may expect that this means everyone is getting chest
compressions, having artificial heart and lung support, and being fed through tubes.
This is not the case; intensive care units across the nation already limit full lifesustaining technology to a many of its patients. In one nationwide study, 74% of
patients received less than full ICU support when facing end-of-life decisions. 24% of
patients were DNR. 14% of patients didnt get life support. 36% of patients had
withdrawn a form of life support that they were on. These are median values,
however. The craziest thing is that ICU practices around CPR and life support around
the country are extremely variable . If we look at the number of deaths that were
preceded by CPR, as in they did CPR and then the patient died again or remained

dead, for some ICUs this was 4% of deaths. For other ICUs, this was 79% of deaths.
So the two take-away points are that limitations on resuscitation are fairly common,
although there is no consensus on the approach to end-of-life decisions.
Some people, taking all this in, opine that our cultures obsession with extending life
and its medical optimism has engendered a troubling relationship between us and
advanced cardiac life
support (CPR, defibrillation,
airway, etc). Instead of
calling it DNR, these people
say, we should call it DNAR
do not attempt to resuscitate
as a reminder that
resuscitation has an
overwhelming failure rate.
We should stop mindlessly
focusing on how to un-stop
stopped hearts and think
about whether the disease
that person has will let that
person have a good chance
of resuscitation and, if
resuscitated, they will live more good years of life. Because of doctors clinical
judgment, they should be the ones giving a decision on CPR or DNR. Some even go
as far as to say that if the doctor refuses to give CPR, the patient cannot insist on it.
Actually, this is what happens in the UK; doctors can go against patient wishes for
CPR if they think that the patient wont survive.
Other people, for example some disability activists (see notdeadyet.org), are
militant against the idea that a doctors judgment of whether a life-sustaining
treatment will be futile can allow them to refuse life-sustaining treatment to an
individual. They take issue with the idea that life with severe disability is a senseless
life. And in fact, physicians underrate the quality of life of people with disabilities
compared to their own ratings of quality of life. So futile care laws that allow
physicians to use their medical judgment to supersede patient wishes may not be a
good thing at all. In fact,
taken societally, they
would allow discrimination
against people with
disability to extend to their
last moments of life,
literally deciding that their
lives are not worth living.
You may hear both of these and think, well, if only healthcare workers and patients
talked about their DNR status before dying and communicated clearly about what
would happen in which instances, these would not be issues. I personally agree with
this, although it seems like one of those things that are simple until you actually try

it. People who are sick want to preserve their life at any cost, whereas well people
want DNR. In addition, while families say that their sick relatives want comfort, the
sick persons themselves often want more treatment even if it did cause pain.
Did you know that the word cardiac arrest did not always mean what happened to
your heart when you died? In the 1950s it was restricted to meaning a complication
of surgery and anesthesia. It was only after the invention of CPR that cardiac arrest
became something natural between life and death (that CPR could then treat). This
tidbit just to say that we are in a historical moment; we cant take any framework or
word for granted, not even death. This is also to say that we are able to develop an
idea of death that isnt associated with cardiac arrest. We can say (and Im being
imaginative here) that someone has died after they have no EEG readings, when
they havent breathed for 10 minutes, when theyre at peace with leaving the world,
after theyve requested euthanasia, and so on and so forth.

The cost of end-oflife care

Medicare spending in the
last year of life is $26,300.
Average Medicare spending
is $4,400. The 5% of
patients who die (require
end-of-life care) account for
24% of total Medicare
spending. Despite the widely recognized high cost of critical care at the end of life,
there is great difficulty in actually reducing these costs. Shifting a patient from the
ICU to another place in the hospital does not actually save that much money, simply
because they were still take up a bed somewhere in the hospital and hospitals are
expensive no matter what. We could encourage more DNRs, but that is a debate
and plus, the most expensive patients are those who were not sure might live or
die. Another idea might be to just have fewer ICU beds, which would work, but the
majority of ICU patients actually benefit from ICU care, while the minority for whom
ICU care is not effective receives the most expensive care. All in all, it is difficult to
identify which patients will be the most expensive patients for the ICU and act on
that.
One thing hospitals could do is move their patients out. Hospice care has blossomed
outside of the hospital setting. Once led by religious and community organizations,
hospice care is now a $17 billion industry, and $15 billion of revenue comes from
Medicare. Not all of the revenue is going back into running the hospices, however;
hospice care is extremely profitable and profit per patient in California has
quintupled in the last 10 years.
Everyone wins: hospice care is able to provide comfortable end of life care for those
who need it and the people who run these businesses are amply rewarded for an
important economic sector in our society. Despite this clear example of market
efficiency, there are some shortfalls in the hospice care industry. Because hospice

care earns more money for gaining patients, their intense patient recruitment
efforts in the search of revenue has led many patients who arent dying into hospice
care. Not only has this resulted in patients staying in hospice care for a longer time,
a substantial portion of patients leave hospice care still alive. In other words,
hospice care chains are recruiting patients who dont need their services and are
not on the brink of death. Consider this: the average nonprofit hospice serves a
patient for 69 days, the average for-profit hospice serves a patient for 102 days, on
average. And this: in a large for-profit hospice chain in Alabama, 48-78% of patients
who enroll in hospice care leave hospice still alive. Uh???????
In summary, end-of-life care is expensive but also incredibly complicated.

Conclusion
Further reading
DNR history
Jeffrey P. Burns, MD, MPH; Jeffrey Edwards, MA; Judith Johnson, JD; Ned H. Cassem,
MD; Robert D. Truog, MD. Do-not-resuscitate order after 25 years. Crit Care Med
2003; 31:15431550
Jeffrey P. Bishop , Kyle B. Brothers , Joshua E. Perry & Ayesha Ahmad (2010) Reviving
the Conversation Around CPR/DNR, The American Journal of Bioethics, 10:1, 61-67
Gainty C, Rees G, Brauner D, Histyo matters. The American Journal of Bioethics
2010; 10(1):76-77.
NYTimes. KAREN ANN QUINLAN, 31, DIES; FOCUS OF '76 RIGHT TO DIE CASE.
Published: June 12, 1985
THOMAS J. PRENDERGAST, MICHAEL T. CLAESSENS, and JOHN M. LUCE. A National
Survey of End-of-life Care for Critically Ill Patients. AM J RESPIR CRIT CARE MED
1998;158:11631167.
Cost and cost saving
Christopher Hogan, June Lunney, Jon Gabel and Joanne Lynn. Medicare Beneficiaries'
Costs Of Care In The Last Year Of Life. Health Affairs, 20, no.4 (2001):188-195
JOHNM. LUCE and GORDOND. RUBENFELD "Can Health Care Costs Be Reduced by Limiting Intensive
Care at the End of Life?" American Journal of Respiratory and Critical Care Medicine, Vol. 165,
No. 6 (2002), pp. 750-754.

Peter Whoriskey and Dan Keating. Medicare rules create a booming business in
hospice care for people who arent dying. The Washington Post, December 26, 2013.