Ethical issues surrounding do not attempt resuscitation orders: decisions, discussions and deleterious effects Zoe ¨ Fritz, Jonathan Fuld ABSTRACT Since their introduction as ‘no code’ in the 1980s and their later formalisation to ‘do not resuscitate’ orders, such directions to withhold potentially life-extending treatments have been accompanied by multiple ethical issues. The arguments for when and why to instigate such orders are explored, including a consideration of the concept of futility, allocation of healthcare resources, and reaching a balance between quality of life and quality of death. The merits and perils of discussing such decisions with patients and/or their relatives are reviewed and the unintended implications of ‘do not attempt resuscitation’ orders are examined. Finally, the paper explores some alternative methods to approaching the resuscitation decision, and calls for empirical evaluation of such methods that may reduce the ethical dilemmas physicians currently face. ‘Birth was the death of him’, as the Irish play- wright, Samuel Beckett remarked. In the UK, 68% of the population dies in hospital, 1 and of those, 80% have ‘do not attempt resuscitation’ (DNAR) orders in place. 2 Despite this, patients, caregivers and healthcare professionals are uncomfortable discussing DNAR. 3e5 Perhaps as a result, these conversations do not take place as frequently as they should. 6e8 Misunderstandings about what DNAR means and when it should be instituted abound. 9e11 In addition, there is evidence that DNAR in them- selves can worsen care. 12 13 In this paper, we examine the ethical issues surrounding DNAR, and address the reasons for the reluctance, fear and confusion that are currently prevalent. HISTORY A secret code When cardiopulmonary resuscitation (CPR) was first introduced in the 1960s 14 the intention was that it should be practised on everyone. 15 It was swiftly realised that this was not appropriate, particularly on terminally ill patients, and so ‘subtle’ signs were created to indicate to healthcare professionals that certain patients should be exempted from this aggressive therapy. Red hearts in the notes, 16 and stars written next to patients’ names 17 are two such examples. As these were often prone to misunderstanding, the idea of an explicit ‘ order ’ or ‘code’ developed. Again, clarity was lacking: ‘ not for 222s’ was often written in the notes (‘222’ being the number called to contact the arrest team in many hospitals in the UK) or, in the USA, ‘ no code’ 18 (‘code’ referring to the specific tannoy that would go out to call the resuscitation team). Moreover, it was shown that, in this setting, elective decisions not to resuscitate were not effectively communicated to nurses. 19 Do not (attempt) resuscitation: past to present In 1991 in the UK, the Parliamentary Ombudsman upheld a complaint by the son of an elderly woman who had been given ‘ not for resuscitation status’ by a junior doctor without consultation. 20 A letter to all consultants then followed, asking for clarifica- tion in the guidance. 21 This was duly published in 1993. 22 The impact of the presence of do not resuscitate (DNR) forms was assessed, and thought to demonstrate an ‘important change in the philosophy of care for hopelessly ill patients’. 23 DNR was later changed to ‘do not ATTEMPT resuscitation’ (DNAR) to try to convey that the chance of successful resuscitation was low 24 ; patients and relatives have been shown to have unrealistically high expectations of the chances of survival from attempted resuscitation 25 thought to be partly due to the success rates portrayed on television. 26 In addition, the important step was taken of making the DNR form an easily visible form, often put at the front of notes. This served the critical purpose of making it immediately accessible in the event of a patient’s arrest, rather than healthcare workers having to trawl through the notes to find whether an instruction regarding resuscitation was written somewhere. Having a separate form on the front of the notes, however, also immediately identifies those patients who are not for resuscitation as being different from those who are. A DNAR is an instruction to withhold resusci- tation. It should not affect any other aspect of care. 27 A DNAR form is filled in when a physician believes that a patient would not benefit from attempted resuscitation, or at a patient’s request. In the UK, there is no legal obligation to tell a patient that such a form has been completed concerning their care and a patient has no legal right to demand its removal. 28 There is still no uniformity, in the UK or in the USA, in these forms, although the Resuscitation Council (UK) has recently developed what it hopes can be a national approach. Ethical issues abound in relation to DNAR orders (colloquially and hereafter in this paper referred to simply as ‘DNAR ’): first in deciding whether or not a patient should be a candidate for resuscitation; Cambridge University Hospitals NHS Foundation Trust, UK Correspondence to Dr Zoe ¨ Fritz, Department of Acute Medicine, Cambridge University NHS Foundation Trust, Box 275, Hills Road, Cambridge, CB2 0QQ, UK; zoefritz@gmail.com Received 29 January 2010 Revised 12 May 2010 Accepted 17 May 2010 Published Online First 31 July 2010 J Med Ethics 2010;36:593e597. doi:10.1136/jme.2010.035725 593 Clinical ethics group.bmj.com on September 2, 2011 - Published by jme.bmj.com Downloaded from