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Posted on February 6, 2020 at 4:00 AM

In late January 2020, the Department of Veterans Affairs Office of Inspector General published an inspection report criticizing the manner in which a physician obtained consent for DNR orders.

In contrast to significant other guidance, it appears that the OIG is suggesting that an “assent” approach to DNR orders is inappropriate. The OIG determined that the physician failed to engage in a “collaborative discussion with family involvement to include patients’ preferences and quality of life” and that this “likely led to the requests for a reversal of the DNR orders.”

For one patient, the physician documented the following: “I told [the patient] that [cardiopulmonary resuscitation] would be of ‘no help’ since when [the patient] died of cancer [cardiopulmonary resuscitation] could only bring [the patient] back to die again. I told [the patient]I would write ‘DNR order’ unless [the patient] objected. [The patient] did not object…[family members] arrived near end of discussion and I repeated the above to them. I wrote DNR/DNI orders.” The patient and family later asked other physicians to change the code status to full code. 

The OIG determined that the physician “held a strong belief based upon the ethical principles of beneficence and nonmaleficence to not provide cardiopulmonary resuscitation to patients who were terminal and had grim prognoses. The hospitalist’s documentation of the conversations held with these patients appears to be one of stark honesty regarding the current medical picture, the implication that cardiopulmonary resuscitation would not allow the patient to die in peace, and the futility of resuscitation measures.”

When interviewed by the OIG, the hospitalist clearly indicated “no longer wishing to provide care that was medically ineffective, having done so in a past critical care practice. Such treatment conflicted with the hospitalist’s ethical beliefs. Rather, the hospitalist would transfer patients to other physicians for care when necessary . . . .”

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