The following is excerpted, with minor adaptations, from Hoffmann, Levin & Boyle’s Nursing Home Ethics Committee Handbook.
Statement of need for the policy or protocol
The policy should explain why it was developed, i.e., in response to what need.
Statement of purpose
The purpose of the policy is its underlying reason and what it purports to accomplish.
Statement of the principles underlying the policy
This provides staff with some sense of the basis for the policy so that they understand its rationale.
Definitions of the terms used
It is important that a policy be clear and not use vague or undefined terms that could be interpreted in different ways. For this reason a policy should have a definition section where such terms are clearly defined.
Substantive rules or guidelines
This is the meat of the policy. It should set out the decisional criteria the institution wants caregivers to use and under what circumstances. For surrogate decision making, for example, it might state when surrogates may make medical decisions for incapacitated patients and who qualifies as a surrogate.
For decisions to withhold artificial nutrition and hydration for incapacitated patients, it should state when such decisions can be made (e.g., when the patient is terminally ill or in a persistent vegetative state) and who can make them.
The policy and procedures should spell out who does what, and when. Specifically, Choice in Dying recommends that the following issues be addressed:
Need for Policy—Between 1 January and 30 June 2012, sixteen cases involving a conflict between a physician and a patient's family over the writing of a do not attempt resuscitation (DNAR) order came to the ethics committee. In 4 of the 6 cases, the physician wrote the order without obtaining the consent of the family members. In 2 of the 6 cases, the family members wanted the physician to write a DNAR order but the physician felt that such an order would not be appropriate. This policy has been developed to provide guidance to physicians and other health care providers in drafting DNAR orders.
Purpose—The primary purpose of this policy on DNAR orders "is to ensure that decisions regarding cardiopulmonary resuscitation (CPR) for particular patients are made through a medically responsible, ethical, and sensitive process that protects the rights of the patient. The secondary purpose is to ensure that there is adequate communication between the patient and those involved in the patient's care."
A. A DNAR order may be appropriate in a variety of clinical situations and may be compatible with aggressive and intensive medical care or participation in research. A DNAR order has no implication for any other treatment decision. For example, it does not imply that any other forms of medical care or research be withheld. Decisions about other medical interventions should be made independently.
B. All treatments that impose undue burdens on the patient without overriding benefits, or that simply provide no benefits may justifiably be withheld or withdrawn. There is no ethical distinction between failing to initiate and stopping therapy. A justification that is adequate for not commencing treatment is also sufficient for ceasing it.
Cardiopulmonary arrest. The cessation of cardiac or respiratory function.
Cardiopulmonary resuscitation. Immediate, aggressive treatment of cardiopulmonary arrest.
DNAR order. A specific order from a physician not to attempt cardiopulmonary resuscitation if a patient suffers cardiac or respiratory arrest.
Terminal illness. An incurable or irreversible condition caused by injury, disease or illness which to a reasonable degree of medical certainty makes death imminent and from which there can be no recovery despite the application of life-sustaining procedures.
Decision-making capacity. The ability to comprehend information relevant to a decision, deliberate about choices in accordance with personal values and goals and communicate such choices to caregivers.
No medical benefit. CPR is defined as having no medical benefit when, in the considered medical judgment of the responsible senior physician, the patient would not survive CPR.
In the absence of a DNAR order, cardiopulmonary resuscitation must be attempted. However, there are circumstances under which it is medically, legally, and ethically appropriate to consider not providing CPR attempts. This section sets forth criteria for determining when such circumstances are present.
A. CPR should not be initiated when:
B. A decision not to initiate CPR should be considered and discussed with the patient or the patient's surrogate under any of the following circumstances:
A. Patients with decision-making capacity:
B. Patients without decision-making capacity:
C. When there is disagreement about providing CPR:
When there is a disagreement about providing CPR either between the patient or surrogate and the physician, the family and the physician, or members of the health care team and the physician, further discussion and consultation with the institution's ethics committee is warranted. In general, the decision of a patient with decision-making capacity or of a designated surrogate should be honored, unless the responsible senior physician finds the request to be medically ineffective. A physician who finds the decision medically or morally unacceptable, but not medically ineffective, and is unwilling to carry it out should transfer responsibility for that patient to an equally qualified physician.
Adapted from the policy developed by The Clinical Center at the National Institutes of Health. Policy and Communications Bulletin, Medical Administrative Series, nos. 91-97 (1 Nov. 1991).