Bioethics Forum Essay
Denying Ventilators to Covid-19 Patients with Prior DNR Orders is Unethical
When deciding which patients with Covid-19 should get scarce ventilators, should hospitals consider a person’s DNR status – the previously stated wish not to receive cardiopulmonary resuscitation (CPR) to restart the heart and breathing after cardiac arrest? This would seem irrelevant to ventilator allocation, and yet some existing and proposed guidelines for triage during a public health emergency put DNR status in the list of criteria for excluding patients from getting ventilators or other life-saving health care. This approach is in direct opposition to the generally agreed-upon goal of maximizing the number of survivors, and could result in confusion and public mistrust of the health care system.
States across the country are working furiously to respond to the Covid-19 pandemic, including developing protocols for allocation of ventilators. While these protocols vary in terms of the clinical considerations and ethical principles upon which they are based, they generally all agree that the goal is to save the most lives possible. Significantly, most state protocols emphasize reliance on only clinical factors to evaluate patients’ likelihood of survival.
Many of these plans agree on a three-step process for resource allocation: application of exclusion criteria, assessment of mortality risk, and periodic clinical assessments. While some proposed plans eliminate step 1, most apply exclusion criteria in order to identify patients with a high risk of mortality even with ventilator therapy, in order to prioritize patients most likely to survive.
For example, in 2015, the New York State Task Force on Life and the Law issued Ventilator Allocation Guidelines for health care institutions to use in an influenza pandemic if the demand for ventilators exceeded the supply. The guidelines were clear that the definition of survival “is based on the short-term likelihood of survival of an acute medical episode and is not focused on whether the patient may survive a given illness or disease in the long-term (e.g., years after the pandemic).” In drafting and releasing the guidelines, the Task Force, the clinical workgroups that developed the clinical protocol for adults, and the New York State Department of Health considered — and unanimously rejected — inclusion of known DNR status in the list of exclusion criteria.
In contrast, in consulting with policymakers who are crafting ventilator allocation protocols specific to the Covid-19 pandemic, we have learned that some proposals consider including a patient’s previously-stated DNR status as an exclusion criterion. Further, some regional plans for triage (for example, from the North Texas Mass Critical Care Task Force and the South Dakota Healthcare Community) include DNR status as criteria for excluding patients from hospital admission or transfer. But excluding patients based on their DNR status is in direct opposition to the generally agreed-upon goal of maximizing the number of survivors, and could result in confusion and public mistrust — both now and in the future.
In an institution facing a shortage of ventilators, a patient whose medical record has a DNR order would be denied access to ventilator therapy upon presentation to the acute care facility, even if her likelihood of survival is high. Consider the hypothetical example of a patient who requested a DNR order several years ago, before having emergency heart surgery, because she did not want to have CPR performed if something went wrong. She fully recovered from that surgery, but now is admitted to the hospital for Covid-19 symptoms. Because her medical record includes the DNR order (which she may not even remember), she would be ineligible for ventilator therapy, even if she had no comorbidities and her odds of surviving with ventilator therapy were high.
We do not object to patients’ choosing to refuse ventilator care and/or to be declared DNR upon admission for care for Covid-19. We do not even object, if clinically necessary, to universal DNR status for Covid-19 patients if it is consistently and transparently implemented. However, excluding patients with a known DNR from being considered to receive ventilator care is inherently problematic. Such an order is only a decision about CPR and does not relate to any other treatment. DNR orders are not an individual or medical professional’s assessment of a patient’s chance of survival; instead they reflect the patient’s medical treatment preferences in the particular context of a decision whether to accept CPR.
Thus, a patient’s decision about DNR status is not necessarily indicative of what he or she would choose about access to a ventilator or other potentially lifesaving care and so does not hold up as a reliable proxy for autonomous decision-making of a person with Covid-19. And DNR status certainly is not indicative of a patient’s immediate or near-immediate mortality with aggressive therapy.
Further, while the primary focus today is–rightfully–managing the Covid-19 pandemic, denying patients with the virus access to ventilator therapy based solely on a prior DNR order would have enormous ramifications for patient decision-making in the future, and could very well undermine the public’s trust in their physicians and the medical enterprise. Patients are often reluctant to consent to DNR because of the fear that they will not receive beneficial treatment. And there is already some justification for this fear. A study of physicians and residents found that many thought that DNR orders can or should be “broadly applied to a variety of other therapies”–thereby deterring patients and/or their proxy decision-makers from consenting to DNR orders when they are medically and/or personally indicated. If allocation plans for Covid-19 made previously-declared DNR status a reason for denying a ventilator to a patient, more people would likely refuse to sign a DNR order and demand full code under any circumstances–even when it is not medically indicated — due to fears that they would later be denied a ventilator (or any other life-saving intervention).
The 2015 New York Guidelines represent the culmination of more than nine years of analysis, research, and consensus-building on the ethical principles and clinical ventilator allocation guidelines. Flexibility must be built into scarce resource allocation plans to allow states, as well as institutions and health care providers, to adjust to changing clinical information. While we laud any initiative to provide clear, succinct guidance to health care providers and institutions who are being faced with near-impossible resource allocation decisions, the inclusion of previously-stated DNR status as an exclusion criterion in ventilator allocation plans will undermine trust in the very system that should be protecting the population’s health during this public health emergency.
Valerie Gutmann Koch, JD, was the senior attorney and special consultant to the New York State Task Force on Life and the Law and is currently the director of law and ethics at the MacLean Center for Clinical Medical Ethics at the University of Chicago and faculty fellow at DePaul University College of Law. Twitter: @vgkoch. Susie A. Han, MA, was the deputy director of the New York State Task Force on Life and the Law and the project chair of the Ventilator Allocation Guidelines and is currently a partner at Venture Catalyst.
This is an important discussion, and I agree, decisions around access to ventilators is one that is important and complex. I think that this discussion highlights important aspects of this issue but oversimplifies the term DNR. The term DNR does refer to whether or not, in the setting of a sudden cardiac arrest, a patient would want to have one of several therapies which can include intubation, mechanical ventilation, chest compressions and resuscitation medications. It does not however indicate that providers will not provide other life-saving interventions when indicated. While the term DNR is commonly used, it often refers a broader set of orders more appropriately termed advanced directives. For example, in Massachusetts, the MOLST form outlines exactly what procedures a patient would and would not want. This includes intubation, invasive and non-invasive ventilation as well as artificial nutrition and dialysis. Most practitioners would use the indication of a DNR as a launching point for discussions regarding what the patient would or would not want prior to the need for cardiopulmonary resuscitation. Especially with patients with severe pneumonititis from COVID-19, it’s important to determine the extent of the advanced directive, as many patients will not only require mechanical ventilation, but also hemodialysis, central line placement and other invasive procedures. The decision to intubate and ventilate a patient is complex, and involves patient presentation, comorbidities, quality of life, and potential outcome. While provider gestalt can play a role, several scoring systems are also available to assess potential outcome. Language is important, and given the potential scarcity of resources like ventilators, ICU beds and the staff to run them, it is important to address these issues in advance. The term DNR is ambiguous and can be confusing to the lay public. Using the term advanced directive and helping the lay public to understand what an advanced directive entails is imperative as we face this crisis and others that may follow. This article is important, raises some excellent points and ethical issues, as well as the importance of language. Thank you.
Thank you, Dr. Wood, for your thoughtful comment.
We agree with much of what you say, and it is precisely the ambiguity around the term “DNR” – and why it shouldn’t be used as a proxy for other life-saving interventions — that we seek to clarify. As we noted in our post, “a patient’s decision about DNR status is not necessarily indicative of what he or she would choose about access to a ventilator or other potentially lifesaving care and so does not hold up as a reliable proxy.” We strongly encourage and support thoughtful “discussions regarding what the patient would or would not want prior to the need for cardiopulmonary resuscitation,” as well as a full understanding of a patient’s advance directives (including, if it exists, a patient’s POLST form). In fact, we sincerely hope these discussions occur when a patient is admitted for Covid-19 (or any other illness). And we applaud efforts to encourage all individuals to engage in advance care planning now, so that individuals and their families can think through these difficult decisions in advance of illness.
Rather, our objection lies with scarce resource allocation protocols that undermine these very discussions, by excluding patients with a record of “known” or “previously-stated” DNR from ventilator therapy. Including a previously-stated DNR order as an exclusion criterion in resource allocation plans would not allow any discussion with the patient or understanding of the patient’s medical prognosis and the patient’s wishes.
Would it be important to communicate with the public about their options under the DNR, advance directive or healthcare proxy regarding intubation?
As I understand, intubation is a traumatic, painful procedure, dangerous to the doctor, and in the case of very elderly people causes tremendous distress and suffering with almost no hope of success.
The government should let the public know they should engage in advance care planning before a crisis arrives.
The circumstances for making a DNR and an Advanced Directive (AD) are completely different. An AD is recommended for all patients,etc. A DNR is only considered necessary for patients with multiple commodities and a a discussion about “end of life” issues. Not everyone should have a DNR but everyone should have an AD.
I am not sure what the background of those with this opinion,but I would guess their years in the “trenches” is limited if at all. Without hesitation, I would not give a ventilator to a DNR patient. A DNR patient is a patient that has decided due to their health status, to not participate in the medical “drama” that comes with end of life care.
I would hope that other health care professionals, would respond to this article as well.
Interesting article… I do believe most ethicists as well as clinicians would not agree with universal Covid DNR.even knowing that cardiopulmonary arrest is Not a good sign in the course of Covid . Multiple allocation protocols are in place to address shortage of critical supplies including ventilators. As far as I can tell they place a very high priority on critical discussions at the time of admission with a review of patient wishes included. All things being considered equal, if no acute communication was available, I would use a patient’s prior DNR as a hint that they should receive all therapies available but not be placed on a ventilator if another patient has equal “qualifications” but does not have a current DNR statement. Ps a small point, the example given by the authors is most unusual, sinc DNR’s are usually cancelled at time of major surgery.
I’m glad that you shared this helpful info with us.
This surely helps many people. Thanks a lot.
This is exactly the scenario I fear most: that a nosy do-gooder medical professional will decide “surely she doesn’t mean in THIS situation….,” if I land in the hospital unconscious with COVID – or anything short of actual brain death. I do not want a ventilator, intubation or a feeding tube. Never. Not for any reason. Under no circumstances.
It is sad to see someone – yet again – attempt to “advocate” “for” patients who do not want their services, and override our wishes to avoid exactly theis kind of “ help.” Just how many more hoops will patients have to jump through in order to make clear to medical professionals and the “ALWAYS err on the side of life” folks that we do not want their treatments!?
To Ms. Valerie Gutmann Koch:
My father died from complications from COVID19. He contacted this at the nursing home where he was a resident. They tested weekly and the virus was brought in by a staff member, My father was removed to another facility to be in isolation. At the time, he was asymptomatic . Within a few days, he started to have a fever and a cough that was being controlled with medicine. When my father was moved to the isolation facility, they asked my mother what kind of care would she like for my father and she said adamant “Everything except resuscitation.” but they had her sign a DNR and did not explain it thoroughly. When my father’s oxygen started to get low all he received was oxygen not a ventilator. My father was susceptible to pneumonia so I knew his lungs were compromised and a ventilator may be necessary. Because of the DNR, he was not given a ventilator. I don’t know if this was going to save him but he was not even given a fighting chance.