Do-Not-Resuscitate Orders

A statement in the medical record that cardiopulmonary resuscitation will not be performed.

The do-not-resuscitate (DNR) order, which averts CPR in cases of cardiopulmonary arrest, has been particularly useful in preventing unnecessary and unwanted invasive intervention at the end of life. Currently, resuscitation is attempted except in cases in which it would not be effective or that are not in accordance with the desires or best interests of the patient. This default position evolved slowly over recent decades. There is a question of whether the decision to issue the order not to resuscitate belongs to the physician or patient. The New York statute, for example, permits the patient or surrogate to choose resuscitation even if health care practitioners believe it will result in extremely poor subsequent quality of life. Conversely, interpretation by the New York State Department of Health provides for physicians to write a DNR order over patient or family objections in the rare cases of "DNR futility," referring to the very specific circumstances in which resuscitation would be physiologically ineffective. However, even if the physician claims futility as a basis for overriding the patient's or surrogate's decision, the issue must be raised first with the patient or his guardian. In most other jurisdictions, the policies and procedures related to DNR orders are somewhat less demanding. Most hospitals, nursing homes, and home health care agencies have policies for situations in which the likely benefit of CPR is so slim and the burden on the patient so great that a DNR order is appropriate. Most institutions require that resuscitation be discussed with the patient or family, although not that it be raised as a question open for their decision.

Physicians should discuss the possibility of cardiopulmonary arrest with patients, describe CPR procedures, and elicit patients' preferences about interventions. Ideally, discussion takes place in an outpatient setting or early in hospitalization as part of a discussion of general treatment preferences. Under these circumstances, patients are more likely to be mentally alert and relaxed, which helps ensure understanding and thoughtful participation in the decision-making process. Subsequent periodic discussions can determine if the patient has changed his mind due to changes in his condition or in treatment alternatives.

If a patient is incapable of making a decision about CPR, the surrogate may make the decision based on the patient's previously expressed preferences or, if such preferences are unknown, in accordance with the patient's best interests.

No matter who decides, some system should exist for communicating, recording, and reviewing the decision. There is no widely recognized case in which a physician or institution was found liable for respecting a DNR order that was authorized after being discussed with the patient and family and being recorded in the patient's medical record.

It is essential to clarify that DNR does not mean do not treat. Only CPR will not be performed. Other treatments (eg, antibiotics, transfusions, dialysis, ventilatory support) may and should still be provided if indicated. More specific orders are required to indicate whether the person should be hospitalized, treated in an intensive care unit, or subjected to other interventions.

Many hospitals and long-term care facilities have policies to guide decisions about resuscitation. These policies vary widely; some reserve the decision for the physician, whereas others allow patients or designated surrogates to decide. Hospital medical staffs should periodically review their experience with DNR orders, revise their DNR policies as appropriate, and inform physicians about their role in the decision-making process.