Chest
Volume 132, Issue 3, September 2007, Pages 748-751
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EDITORIALS
POINT/COUNTERPOINT EDITORIALS
Point: The Ethics of Unilateral “Do Not Resuscitate” Orders: The Role of “Informed Assent”

https://doi.org/10.1378/chest.07-0745Get rights and content

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The Value and Risk of Informed Assent

In the critical care setting, there are specific circumstances when some standard therapies, such as cardiopulmonary resuscitation, may not provide any benefit to the patient. In these circumstances, are clinicians always obliged to obtain informed consent from patients or family members to withhold or withdraw such therapies? Because the process of obtaining informed consent may cause considerable distress for some patients and family members, we contend that obtaining informed assent—when the

Three Categories of Withholding or Withdrawing Life Support

In the ICU, we can identify three categories of decisions to withhold or withdraw life-sustaining therapies that clinicians believe are clearly not indicated; the concept of informed assent is not equally relevant for all three categories. The first category is withholding treatments that patients or family members are not likely to expect for the patients' specific condition (for example an exploratory laparotomy or activated protein C for a moribund patient with severe septic shock and

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      Although the Western tradition considers withholding and withdrawing to be ethically equivalent, many providers, patients, and surrogates experience them in different ways.37 Once life-sustaining therapies are initiated, the choice to withdraw those therapies (rather than withhold them in the first place) appears to evoke even more significant discomfort.38 Experiences vary widely, but multiple studies demonstrated this discord in experience between withholding and withdrawing life-sustaining therapies at the end of life.

    • Evolution of Investigating Informed Assent Discussions about CPR in Seriously Ill Patients

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      Additional challenges include the generally low quality of communication between physicians and seriously ill patients, a topic Dr. Curtis has devoted much of his career to addressing via rigorous, high-quality research.8-13 This confluence of poor CPR outcomes in specific clinical contexts, deep and nuanced understanding of the burden decision-making can impose on patients and families,9,14,15 and expertise in medical ethics became the nidus for a new concept of discussing withholding certain forms of life support that Curtis and Burt termed ‘informed assent (IA). 16 IA seeks to balance the ethical tensions between appropriate beneficence and inappropriate medical authoritarianism by simultaneously offering full information to patients and families and removing decision-making burdens around specific, generally expected, therapeutic interventions such as CPR.

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    The authors have no conflicts of interest to disclose.

    Editor's Note:As part of our ongoing Medical Ethics series, we offer this POINT/COUNTERPOINT Debate and frame it with the following vignette: At Grand Rounds regarding end-of-life issues, a visiting professor offered that when cardiopulmonary resuscitation (CPR) is unlikely to promote survival with a reasonable quality of life, he shares his assessment with the patient. If the patient does not object, he enters a “no CPR” order in the patient's medical record.

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