Comparison of medical and nursing attitudes to resuscitation and patient autonomy between a British and an American teaching hospital

In the last 30 years, cardiopulmonary resuscitation (CPR) has evolved from an intervention indicated only in cases of acute insult to an otherwise healthy body to a default measure employed in virtually all cases of cardiac failure. The high cost and low efficacy rate of CPR has provoked questions about the moral and economic wisdom of its routine use, particularly for elderly patients with serious comorbidity. This paper presents the results of a comparative study of decision making practices concerning "Do-Not-Resuscitate" (DNR) orders in British and American hospitals. Thirty-four physicians and nurses in one American and one British hospital were interviewed about their decision making practices. Qualitative methods of data analysis were employed. The study revealed that while the American and British hospitals had adopted similar formal protocols for DNR decision making, in practice the British physicians often made DNR decisions unilaterally, whereas the American physicians sought the patient's or surrogate's consent in every instance, even where it was not legally required. The British decision making model enables physicians to reduce the inappropriate use of resuscitation, but at the expense of patient autonomy. In contrast, the American approach fully respects patient autonomy, but except in cases of medical futility grants physicians no authority to refuse to render treatments that are in their judgment contraindicated.