Medical Futility and Unilateral DNR

1Cleveland Clinic Foundation, Cleveland, OH
2Cleveland Clinic Foundation, Cleveland, OH

Meeting: Hospital Medicine 2010, April 8-11, Washington, D.C.

Abstract number: 283

Case Presentation:

A 84‐year‐old male with a history of seizure disorder and in persistent vegetative state presented with recurrent UTI. Ultrasound of testis, performed in view of scrotal swelling, revealed marked bilateral scrotal edema with subcutaneous emphysema. Urology was consulted for Fournier's gangrene, but patient's family, including his legal guardian, refused surgery and opted for a trial of conservative management with broad‐spectrum intravenous antibiotics but also requested that patient remain full code. The scrotum eventually began to ulcerate and the dependent part of the scrotum eventually slowly sloughed off. The patient's family refused transfer to LTAC and insisted on taking him home. Initially, they also refused any kind of central line access for home intravenous antibiotics. The physician's concern with The medical futility of resuscitation was discussed with family, which continued to demand that the patient remain full code. Bioethics, social work, and an ombudsman were consulted for assistance. Against the advice of the physician, patient remained full code. The family eventually agreed to Hohn catheter placement, and the patient was subsequently discharged home with intravenous antibiotics and wound care.

Discussion:

Medical futility refers to a physician's determination that a therapy will be of no benefit to a patient and therefore should not be prescribed. A patient's right to treatment that is medically futile is limited by the physician's role to provide scientifically proven treatment that is ethical and within the legal framework. Specifically, although physicians are not required to perform CPR when it is medically futile, they should seek agreement with patients and surrogates before writing so‐called unilateral DNR orders. Attempts to resolve conflicts between physicians, patients, and surrogates regarding medically futile treatments should be made by employing a procedural approach through a predefined process handled on a case‐by‐case basis that includes multiple safeguards to ensure that a patient's rights and wishes are fully protected. Such approaches and processes should include designated groups such as bioethics and legal. Writing a unilateral DNR order over the objection of a patient or surrogate should be reserved for exceptionally rare and extreme circumstances after thorough attempts to resolve disagreements have been tried and have failed. Patients and surrogates should also be given the opportunity to transfer the patient's care before the DNR order is implemented.

Conclusions:

All attempts should be made to inform and resolve disagreements between physician, patient and surrogate regarding all treatments, but especially those that are understood to be medically futile. A case‐by‐case approach with appropriate institutional support offers the best possible framework to discuss medical futility with patients and surrogates.

Author Disclosure:

S. Kandpal, none; M. Gerrek, none.

To cite this abstract:

Kandpal S, Gerrek M. Medical Futility and Unilateral DNR. Abstract published at Hospital Medicine 2010, April 8-11, Washington, D.C. Abstract 283. Journal of Hospital Medicine. 2010; 5 (suppl 1). https://www.shmabstracts.com/abstract/medical-futility-and-unilateral-dnr/. Accessed December 11, 2019.

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