The Veterans Administration, under a new policy that recognizes a patient's right to die, now permits doctors who practice in the nation's 172 veterans' hospitals to write explicit orders denying lifesaving medical therapy to certain critically ill patients.
The new rules allow doctors in VA hospitals to signify in advance with a "no-code" or "do not resuscitate" order that a dying patient whose heart or lungs fail should not be saved with resuscitation, which usually means the doctor pounds on the patient's chest or administers electric shocks to his heart.
Although many public and private hospitals have adopted "no-code" policies for their medical staffs, the VA, which runs the largest hospital system in the country with 1.2 million annual patient admissions, formally prohibited such orders in 1979.
The new policy, which went into effect three weeks ago, requires such orders to be written in a patient's medical chart. The "no-code" decision must be made by a senior physician with the patient's permission, or, if the patient is not legally competent, the consent of the family.
The policy prohibits "no-code" orders in cases where a patient requests "voluntary euthanasia." Nor can doctors "take any affirmative steps to 'hasten the patient on his/her way.' "
The primary reason for the new policy, according to VA official Dorothy Rasinski, is that the previous policy seemed to violate the rights of patients who wanted to forgo lifesaving therapy when they or their doctors agreed that it was futile.
But if a doctor decided not to resuscitate such a patient, under the old policy he could not formally write that in the chart, Rasinski said. Thus if a patient suffered cardiac arrest while that doctor was not on duty the patient might be resuscitated against his wishes. In some cases, a VA official said, doctors did not include patients or families in the decision to withhold therapy.
"The main effect of the new policy is to put medicine back on the record," said Alexander Capron, director of the President's Commission on for the Study of Ethical Problems in Medicine, which last spring recommended that the VA adopt new rules that respect patients' rights to forgo lifesaving therapy. He said the new policy "takes what have been subterranean . . . decisions" and makes them "legitimate." Some physicians in VA hospitals openly disregarded the old policy, which said "no-code" orders were "inappropriate and do not contribute to high-quality patient care."
In a Washington Post report last spring, some doctors who worked at the Veterans' Hospital in Washington said they would make informal arrangements with nurses and resuscitation teams to allow certain hopelessly ill patients to die, or would delay beginning resuscitation in order to ensure that it would not succeed for certain patients.
This sometimes resulted in confusion, and some patients were resuscitated against their wishes, the doctors said. One of those doctors, Mitchell Dunn, now the chief resident at George Washington University Hospital, said the new policy "gives the physician the opportunity to play within the rules and still do things right." Rasinski said the VA policy "legitimizes what physicians have sought to do in the past, to ease the patient's suffering and conform with the patient's wishes . . . where it was obvious that death was imminent, that the downhill course was essentially irreversible, and where even if the patient was successfully resuscitated, there was no reasonable expectation that the patient would recover."