DNR orders in a public health crisis


Under normal circumstances, Opinion 5.4, "Orders not to attempt resuscitation (DNAR)," of the AMA Code of Medical Ethics vests authority to accept or request DNAR status with the patient (or surrogate), not the treating physician, and instructs physicians to provide resuscitation when the patient's wishes are not and cannot immediately be known. Can it ever be ethically justifiable for physicians to withhold cardiopulmonary resuscitation (CPR) unilaterally? Under certain conditions, the answer may be "yes."

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In Opinion 5.5, "Medically ineffective interventions," the Code directs physicians to recommend and provide only those interventions "that are medically appropriate—i.e., scientifically grounded—and that reflect the physician's considered judgment about the risks and likely benefits of available options in light of the patient's goals for care." Physicians are required neither to offer nor to provide care that "cannot reasonably be expected to yield the intended clinical benefit or achieve agreed-on goals for care." When CPR cannot reasonably be expected to offer clinical benefit, Opinion 5.5 thus allows physicians to withhold it without explicit consent from the patient or surrogate even under usual conditions.

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Under conditions of scarcity in a public health crisis, physicians' ethical obligations to protect the health of the public, to ensure the availability of professional caregivers and to prudently steward limited resources may similarly justify withholding resuscitation without seeking patients' agreement.

Opinion 8.3, "Physician responsibilities in disaster response and preparedness," sets out physicians' responsibility to provide care even at risk to themselves, but also to balance the "risks of providing care to individual patients versus the need to be available to provide care in the future." In a public health crisis, the goal is to maximize benefit (and minimize harm) for the greatest number of patients. Carrying out CPR for a patient who is being treated for a severe, highly contagious disease may pose an unacceptably high level of risk for health care professionals involved in the resuscitation effort, especially when there is little likelihood the patient will survive.

In a 2010 report, the AMA's Council on Ethical and Judicial Affairs offers insight about what conditions would justify withholding resuscitation (PDF). These include the transmissibility and severity of the disease in question, the level of risk of exposure to health care personnel involved in the resuscitation and the risks that caregivers might in turn pose to others should they become infected.

Additional ethics guidance in a pandemic

The AMA offers an overview of foundational guidance regarding medical ethics for health care professionals and institutions responding to the COVID-19 pandemic.