DNR (DO NOT RESUSCITATE)

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In its most simple form, "DNR" is a physician's order directing a clinician to withhold any efforts to resuscitate a patient in the event of a respiratory or cardiac arrest. The literal form, do not resuscitate, is more precisely worded as do not attempt resuscitation. While originally intended for hospitalized patients, the concept of withholding resuscitative efforts has since been extended to include patients in nursing homes, children with incurable genetic or progressive neurologic diseases, and terminally ill patients in the home or hospice setting.

More broadly, the DNR order has become a part of the ritual of death in American society. For the patient, a DNR order (or the absence of a DNR order) establishes how death will likely ensue. The introduction of DNR orders also marked a pivotal change in the practice of medicine, for it was the first order to direct the withholding of treatment. DNR orders are so commonplace and widely accepted in everyday practice that nearly all physicians and nurses have had some experience in determining whether to invoke or adhere to the order when it is written.

History

Although commonplace and widely accepted today, the development of the do-not-resuscitate order was, and remains, controversial on several fundamental issues at the intersection of medicine and ethics. As with artificial (mechanical) ventilation and artificial nutrition and hydration, the development of advanced cardiopulmonary resuscitation (CPR) techniques created decision points regarding treatment alternatives for both dying patients and their caretakers that had not previously been confronted.

Prior to 1960 there was little that physicians could do for a patient in the event of sudden cardiac arrest. In that year, surgeons at Johns Hopkins Medical Center reported a technique for closed-chest massage combined with "artificial respiration" and designed specifically for patients suffering anesthesia-induced cardiac arrest. This condition was especially conducive to closed-chest massage because it often occurred in otherwise healthy patients who needed only short-term circulatory support while the adverse effects of anesthesia were resolved. In the context for which it was designed—transient and easily reversible conditions in otherwise healthy individuals—the technique at first appeared miraculous for its effectiveness and simplicity. A 1960 article in the Journal of the American Medical Association stated: "Anyone, anywhere, can now initiate cardiac resuscitative procedures. All that is needed are two hands" (Kouwenhoven, Jude, and Knickerbocker, pp. 1064–1067).

Partly because of its simplicity, and partly because of uncertainty over who might benefit from the performance of CPR, it soon became the rule and not the exception that any hospitalized patient experiencing cardiac arrest underwent a trial of resuscitative efforts. These attempts often transiently restored physiologic stability, but too often also resulted in prolonged patient suffering. By the late 1960s, articles began appearing in the medical literature describing the agony that many terminally ill patients experienced from repeated resuscitations that only prolonged the dying process (see Symmers).

Soon a covert decision-making process evolved among clinicians regarding the resuscitation decision. When physicians and nurses responded to situations in which they believed that CPR would not be beneficial, they either refused to call a code blue or performed a less than full resuscitation attempt. New terms, such as slow code and Hollywood code, entered the vocabulary of the hospital culture as these partial or half-hearted resuscitation efforts became more pervasive.

Lacking an established mechanism for advanced decision making about resuscitation, some hospitals developed their own peculiar means of communicating who would not receive a full resuscitation attempt in the event of cardiopulmonary arrest. Decisions were concealed as purple dots on the medical record, written as cryptic initials in the patient's chart, or in some cases simply communicated as verbal orders passed on from shift to shift.

The absence of an open decision-making framework about resuscitation decisions was increasingly recognized as a significant problem in need of a solution. Unilateral decision making by clinicians in this context effectively circumvented the autonomy of the patient and prevented the full consideration of legitimate options by the involved parties prior to a crisis. From the patient's perspective, this covert decision making resulted in errors in both directions: some patients received a resuscitation attempt in circumstances where they did not desire it, while others did not receive a resuscitation attempt in circumstances where they would have desired it.

In 1976 the first hospital policies on orders not to resuscitate were published in the medical literature (see Rabkin). These policies mandated a formal process of advance planning with the patient or patient's surrogate on the decision of whether to attempt resuscitation, and also stipulated formal documentation of the rationale for this decision in the medical record. In 1974 the American Heart Association (AHA) became the first professional organization to propose that decisions not to resuscitate be formally documented in progress notes and communicated to the clinical staff. Moreover, the AHA position on DNR stated that "CPR is not indicated in certain situations, such as in cases of terminal irreversible illness where death is not unexpected" (American Heart Association).

Ethical Perspective

Parallel to the development of the DNR order in the medical community was the emergence of a broad societal consensus on patient's rights. The conceptual foundation of this consensus was the recognition that the wishes and values of the patient should have priority over those of medical professionals in most healthcare decisions.

An influential President's Commission further advocated that patients in cardiac arrest are presumed to have given consent to CPR (that is, a resuscitation attempt is favored in nearly all instances). By extension the commission argued that the context in which the presumption favoring CPR may be overridden must be explicit, and must be justified by being in accord with a patient's competent choice or by serving the incompetent patient's well-being (President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research). Since that time nearly all states have adopted specific statues on the DNR order. The bioethics community, however, has not embraced this view without dissent.

The assumption that CPR is generally beneficial and should be withheld only by exception has been seriously challenged. CPR, the argument goes, is often not beneficial and was never intended to be the standard of care for all situations of cardiac arrest (four of the five patients in the original Johns Hopkins report experienced an unanticipated cardiac arrest in the setting of anesthesia). From this perspective, CPR, like any treatment, should only be offered to those patients for whom it is medically indicated—physicians are not ethically bound to seek consent to refrain from a procedure that is not medically indicated.

Few issues have been more contentious than whether a physician may determine, without patient or surrogate consent, that CPR is not indicated. Some hospitals have adopted a "don't ask, don't tell" approach to this question by allowing unilateral or futility-based DNR orders without asking or informing the patient of the decision. Still other policies employ a "don't ask, do tell" approach, where unilateral DNR orders can be written at the discretion of the attending physician, who then informs the patient or patient's family of the decision.

Attempts have been made within the medical profession to define futile, nonbeneficial, inappropriate, or not indicated in specific terms, such as lack of physiological effect or low likelihood of survival. The assumption underlying this approach is that physicians are best qualified to determine whether and when a medical therapy is indicated. Others advocate procedural resolution pathways, in the belief that it is not possible to achieve consensus on an accepted definition of what constitutes futile medical treatment. This approach assumes that end-of-life decisions inherently involve value-laden choices that people will not always agree on.

Who ultimately decides when a treatment is indicated? The original foundation of the consent process in medicine is the principle that permission is needed "to touch," even when the intent of the person who seeks "to touch" is solely to promote health and treat illness. Because the DNR order is an order not to touch—when that touch may be both highly invasive and life-preserving—only a properly informed patient can decide whether touching is wanted or not. This determination is ultimately a value judgment made by the patient, utilizing information as to efficacy (or futility) provided by the physician.

Conclusion

The introduction of the DNR order brought an open decision-making framework to the resuscitation decision, and also did much to put appropriate restraints on the universal application of cardiopulmonary resuscitation for the dying patient. Yet, DNR orders focus upon what will not be done for the patient, as opposed to what should be done for the patient. These deficiencies are being addressed through the palliative care movement, which recognizes that good care at the end of life depends much more on what therapies are provide than upon those that are not.

jeffrey p. burns

BIBLIOGRAPHY

Alpers, Ann, and Lo, Bernard. 1995. "When Is CPR Futile?" Journal of the American Medical Association 273(2): 156–158.

American Heart Association. 1974. "Standards and Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC), V. Mediolegal Considerations and Recommendations." Journal of the American Medical Association 227: S864–S866.

Baker, Robert. 1995. "The Legitimation and Regulation of DNR Orders." In Legislating Medical Ethics: A Study of the New York State Do-Not-Resuscitate Law, ed. Robert Baker and Martin Strosberg. Boston: Kluwer Academic.

Blackhall Leslie J. 1987. "Must We Always Use CPR?" New England Journal Medicine 317(20): 1281–1285.

Helft Paul R; Siegler, Mark; and Lantos, John. 2000. "The Rise and Fall of the Futility Movement." New England Journal Medicine 343: 293–296.

Kouwenhoven W. B.; Jude, James R.; and Knickerbocker, G. Guy. 1960. "Closed-Chest Cardiac Massage." Journal of the American Medical Association 173: 1064–1067.

President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. 1983. Deciding to Forego Life-Sustaining Treatment: A Report on the Ethical, Medical, and Legal Issues in Treatment Decisions. Washington, D.C.: U.S. Government Printing Office.

Rabkin, Mitchell T.; Gillerman, Gerald; and Rice, Nancy R. 1976. "Orders Not to Resuscitate." New England Journal of Medicine 295: 364–366.

Symmers William S. 1968. "Not Allowed to Die." British Medical Journal 1: 442.

Tomlinson, Tom, and Brody, Howard. 1990. "Futility and the Ethics of Resuscitation." Journal of the American Medical Association 264(10): 1276–1280.

Youngner Stuart J. 1987. "Do-Not-Resuscitate Orders: No Longer Secret, but Still a Problem." Hastings Center Report 17(1): 24–33.

Youngner Stuart J. 1988. "Who Defines Futility?" Journal of the American Medical Association 260(14): 2094–2095.

DNR (Do Not Resuscitate)

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