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After the DNR: Surrogates Who Persist in Requesting Cardiopulmonary Resuscitation

Some health care organizations allow physicians to withhold cardiopulmonary resuscitation from a patient, despite patient or surrogate re­quests that it be provided, when they believe it will be more harmful than beneficial. Such cases usu­ally involve patients with terminal diagnoses whose medical teams argue that aggressive treatments are medically inappropriate or likely to be harmful. Although there is state-to-state variability and a con­siderable judicial gray area about the conditions and mechanisms for refusals to perform CPR, medical teams typically follow a set of clearly defined proce­dures for these decisions. The procedures are based on the principle of nonmaleficence and typically in­clude consultation with hospital ethics committees, reflecting the guidelines of relevant professional as­sociations.

Ethical debates about when CPR can and should be limited tend to rely more on discussions of theory, principles, and case studies than sys­tematic empirical study of the situ­ations in which such limitations are applied. Sociologists of bioethics call for empirical study, arguing that what ethicists and health profession­als believe they are doing when they draft policies or invoke principles does not always mirror what is hap­pening on the ground. In this article, we begin the task of modeling the empirical analy­ses sociologists call for, focusing on a cohort at Massachusetts General Hospital. We inductively analyzed ethics committee notes and medical records of nineteen patients whose surrogates did not accept the decision to withhold CPR.

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