The Globe said the case “appears to have been the first jury verdict for the plaintiff in an illegal extension of the lawsuit for life in the United States, according to several legal experts.” Local EMDC implements the national HAV policy by adopting DNR policies that are consistent (but not necessarily identical) with the national DNR policy. A review of the policies of 37 EMDC found that most policies use language very close to the language of the national directive. Other institutions supplement this wording by describing a specific procedure to be followed in the event of conflicts over DNR assignments. For example, the policy of Jerry L. Pettis Memorial VAMC in Loma Linda, California, explains, “In cases where there are doubts about the accuracy of a DNR prescription or the accuracy of the patient`s prognosis diagnosis, the patient`s case will be referred to the medical center`s ethics advisory committee to resolve the conflict.” 35 Finally, patients resuscitated in the intensive care unit can then be separated from ventilators, he stressed, but “death cannot be reversed.” The courts did not seem receptive to what might be called illegal living cases. Patients in the United States have a well-established right to determine the goals of their medical care and to accept or reject any medical intervention recommended to them by their attending physician. But are patients also entitled to procedures that are not recommended by the doctor? This question is particularly important for an intervention – cardiopulmonary resuscitation (CPR) – since the renunciation of CPR is almost always associated with the patient`s death. Cardiopulmonary resuscitation is also unique among medical interventions in that it is administered regularly without the consent of the patient or surrogate mother. The current Veterans Health Administration (VHA) guideline requires that any patient who undergoes cardiorespiratory arrest receive cardiopulmonary resuscitation unless a physician prescribes a do not resuscitate (DNR) order in advance.1 Nevertheless, cardiopulmonary resuscitation success rates are extremely low in some patient populations, such as patients with acute stroke or sepsis. In some cases, the likelihood of benefit may be so low that some doctors would consider CPR to be unnecessary for medical reasons. The purpose of this report is to examine the difficult situation in which a physician suggests writing a DNR prescription based on medical futility, even if the patient or replacement decision-maker wants CPR to be tried. Although such cases are relatively rare,2,3, they are a very common source of ethical consultation4,5 and are difficult for clinicians, patients and families.

In its 1994 report, Futility Guidelines: A Resource for Decisions About Withholding and Removing Treatment,6,7 the National Ethics Committee (NEC) of the VHA addressed the general issue of futility. In that report, CEN noted that futility was essentially impossible to define and recommended an orderly procedure to deal with disputes related to futility. However, the report did not specifically comment on how futility could be applied to MNR orders. In the years following the publication of the Futility Guidelines report, ethical and legal standards on the subject have evolved. This report expands and updates the previous report and reflects the growing support for procedural approaches in cases where MNR orders and futility are involved. CEN offers this report as a guide for clinicians and ethics advisory bodies in addressing these difficult issues. The recommendations in this report do not in any way modify or exceed the current national policy of the VHA on MNR`s mandates. Jurisprudence in the United States does not provide clear guidance on the issue of futility. Two of the most well-known cases related to futility are Wanglie and Baby K. The Wanglie case22 involved an 86-year-old woman in a persistent vegetative state who was receiving ventilatory assistance in an intensive care unit. Their doctors and the hospital went to court to have a guardian appointed, with the ultimate goal of removing the life support.

The court refused to address the issue of futility, finding only that her husband, over 50, was the best person to be her guardian. Therefore, the impact of this decision is limited to how other courts might rule in cases of futility. The guidelines of several other EMDC describe similar procedural approaches to futility. These guidelines generally emphasize the importance of communication between all parties involved, access to consultations by medical experts and the involvement of the local ethics advisory committee, as well as the possibility of transferring care to another clinician or facility if no agreement can be reached between the patient or surrogate mother and the healthcare team. Procedural approaches recognize that when a predetermined fair trial is used in case of disagreement, consensus is often reached. Despite the differences in language, all of the VAMC guidelines reviewed appear to be consistent with the current official interpretation of the national HAV policy that physicians are not permitted to write a DNR prescription on the objection of a patient and/or their family. La porte-parole de St. Peter`s, Andrea Groom, said Friday that the hospital had not commented on the legal issues. This report examines the difficult situation where a patient or substitute decision-maker wants cardiopulmonary resuscitation to be attempted, even if the physician believes resuscitation efforts would be in vain.

It also discusses the current controversies surrounding do not resuscitate (NRT) prescriptions and medical futility, discusses complex medical, legal and ethical considerations, and provides recommendations as a guide for clinicians and ethics committees in resolving these difficult issues. Disputes over MNR prescriptions and medical futility should not be resolved by a policy that attempts to define insignificance in the abstract, but by a predefined and fair process that deals with specific cases and includes multiple safeguards. In investigating these issues, the report focuses on the Veterans Health Administration (HAV). The current national HAV policy prevents physicians from taking a DNR prescription on the objection of a patient or surrogate mother, even if the physician feels that cardiopulmonary resuscitation is hopeless. The HAV National Ethics Committee recommends that the HAV policy be amended to reflect the views expressed in this report. The National Ethics Committee, which is made up of clinicians and HAV executives, as well as veterans` lawyers, produces reports that analyze ethical issues that affect the health and care of veterans treated in HAV, the largest integrated health care system in the United States.