The "do not resuscitate" order; clinical and ethical rationale and implications.

This paper reviews the rationale for cardiopulmonary resuscitation (CPR) and a "Do Not Resuscitate" order (DNR). It includes the confusion surrounding consent and related treatments; implications and misunderstandings for care givers, patients and families; efficacy; value; unilateral DNRs; and discomfort on the part of physicians to discuss patients' preferences early in treatment. CPR and DNR challenge accepted definitions of beneficence and force us to consider the immediate as well as the long-term value and benefit to patients and families, the concept of futility, and our view of the good. The decision and process to attempt CPR are unique in the practice of medicine. In most institutions, the procedure is attempted unless there is a DNR order. This practice assumes an emergency and a benefit. It reverses the usual and customary practice of informed consent with the justification that the threat of death overrides other contingencies. Many communities consider CPR a public good. They provide support teams and extensive publicly funded training of healthcare professionals and citizens. The underlying philosophy for providing CPR without consent as an emergency procedure is not often articulated. At the time of an arrest, urgent time-pressures, the goals of treatment, likelihood of success, and side effects cannot be reviewed. Prior to an emergency, physicians are often uncomfortable to discuss the potential of cardiac arrest in routine visits, nor do patients initiate this conversation. CPR is predicated on the assumptions that life is sacred, to be maintained, and CPR will be successful; it is consistent with the belief that allowing someone to die is a harm. Patients' medical status and prognosis may mitigate the wisdom of attempting to resuscitate. This paper reviews the principles of best interest and substitute judgment, it provides suggestions to frame and facilitate conversations about DNR related to the larger treatment goals and plans among physicians, nurses, patients, and families. Policies and forms developed at institutions are reviewed to identify mechanisms for improving the process and special circumstances such as the operating room.