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Letters
June 20, 2012

Challenges of Do-Not-Attempt-Resuscitation Orders—Reply

Author Affiliations
 

Letters Section Editor: Jody W. Zylke, MD, Senior Editor.

Author Affiliations: Columbia University Medical Center, New York, New York (Dr Blinderman; cdb21@columbia.edu); Massachusetts General Hospital, Boston (Dr Krakauer); and Harvard Medical School, Boston, Massachusetts (Dr Solomon).

JAMA. 2012;307(23):2487-2489. doi:10.1001/jama.2012.5607

In Reply: We appreciate Dr Perkins and colleagues sharing British consensus guidelines for CPR decision making. We agree with the authors' assessment that guidelines and regulatory processes alone cannot ensure that patients at the end of life are not harmed by CPR and that a focus on communication training is necessary. Communication practices that elicit patients' health care goals, encourage discussion of the likelihood of future outcomes, and lead to recommendations of how to best honor patients' values are essential. Too often clinicians get locked in conflict when patients or surrogates request interventions that physicians deem nonbeneficial or harmful. Our differentiated approach to determining CPR status is not meant to solve the problem of inadequate communication but to create a rational framework for these conversations. Improved communication skills together with guidelines and policies that support the decision to not offer CPR when it is believed to be medically inappropriate or harmful, in our opinion, will be more likely to prevent the harms associated with CPR for terminally ill or dying patients than any single approach by itself.

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