The Decision to Withhold Resuscitation in Australia: Problems, Hospital Policy and Legal Uncertainty

Abstract

Decisions to withhold cardio-pulmonary resuscitation (CPR) should provide explicit clinical and ethical justification, be stated in an unambiguous manner, and be formally documented in the medical chart. Even so, the legal status of decisions to withhold CPR remains uncertain, in part because there is all too often no written justification for a No-CPR order; no statement of the overall management plan subsequent to an order; no indication of who made the decision; no explanation as to what may lead to changes in the decision; and no reference to the wishes of the patient, family or surrogate. The fact that hospital policies regarding No-CPR orders are rare or are ignored may be symptomatic of failures in communication between physicians on the one hand and the patient and the health care team on the other. Communication failures often mask paternalism and concepts such as "futility" and "medical indications" are used to override patient autonomy in decisions regarding cardio-pulmonary resuscitation. In Newcastle, Australia, a recent review of current CPR practice and its ethical implications led to the formulation of policy guidelines concerning the problems of when to initiate CPR and when and how No-CPR orders should be issued.