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March 7, 2012

Time to Revise the Approach to Determining Cardiopulmonary Resuscitation Status

Author Affiliations

Author Affiliations: Department of Anesthesiology, Columbia University Medical Center, New York, New York (Dr Blinderman); Division of Medical Ethics (Dr Solomon), Departments of Medicine (Dr Krakauer) and Global Health and Social Medicine (Drs Krakauer and Solomon), Harvard Medical School, Boston, Massachusetts; Palliative Care Service and Optimum Care Committee, Massachusetts General Hospital, Boston (Dr Krakauer); and Department of Anesthesiology, Children's Hospital of Boston, Boston, Massachusetts (Dr Solomon).

JAMA. 2012;307(9):917-918. doi:10.1001/jama.2012.236

In US hospitals, cardiopulmonary resuscitation (CPR) is the de facto default option—patients must “opt out” by requesting or consenting to a do-not-attempt-resuscitation order. Despite its worthy intent, requiring all patients or their surrogates to consent to a do-not-attempt-resuscitation order to avoid CPR has resulted in an ethically unjustifiable practice that exposes many patients to substantial harms.

Whenever there is a plausible risk of cardiac arrest, the standard approach is to ask patients or their surrogates about their preferences regarding CPR. However, the very act of asking can suggest to the patient and family that CPR may be beneficial, even when the clinician believes otherwise. Additionally, research in cognitive psychology has revealed that default options are often interpreted as recommendations or guidelines, or as the path of least resistance, and that such default options significantly affect decision making.1 For these reasons, patients or their surrogates may be biased toward choosing full resuscitation status, even when CPR likely would bring little or no benefit and would risk considerable harm. Therefore, the standard approach of neutrally seeking consent to withhold CPR may inadvertently diminish patients' and families' comprehension of the clinical situation and lead to decisions that are grounded neither in patients' values2 nor in their best interest.

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