1. Do-Not- Resuscitate order
Competent patient can his/her Advanced Directive when becomes incompetent.
Limitations of ADs:
Only small proportion of incompetent patients had ADs beforehand.
2. AD has to be issued well in advance of the circumstances in which they are to be applied, to ensure the patient’s competence. Thus they tend to be vague and in broad terms.
“ If I am terminally ill and death is imminent, no further artificial or extraordinary means to prolong my life is to be employed”.
3. There is a fear of ADs to be intentionally misused or unintentionally abused.

2. In the absence of AD then somebody has to decide for him (surrogate).
The surrogate is usually a family member (FM) because of the following assumptions:
FM would be the person most accepted by the patient.
FM knows and cares for the patient the most and what would have wanted.
The family is socially recognized as the authority of care for its dependent members.
This is not always the case. FM may have interest that is in conflict with the patient’s interest.
In this case the physician directly responsible for the patient is obliged for the welfare of the patient even by appealing to court.

3. There are certain controversies that arise from the surrogate decision:
The proper procedures for determining whether the patient is incompetent to decide. What is needed is a patient who is capable to understand relevant information about treatment alternatives and to apply his values to one of these alternatives.
When and to what extent the decision of FM should be given weight.
In what cases and to what extent it is desirable or even required to involve others with FM decision (e.g. hospital ethical committee, court to review the decision).

4. Ethics and communication in Do-Not-Resuscitate Orders
If your patient stops breathing or their heart stops beating in the hospital, the standard of care is to perform CPR in the absence of a valid physician's order to withhold it.

5. When can CPR be withheld?
Virtually all hospitals have policies which describe circumstances under which CPR can be withheld.
Two general situations arise which justify withholding CPR:
1. when CPR is judged to be of no medical benefit "medical futility"; and
2. when the patient clearly indicates that he / she does not want CPR, should the need arise.

6. Knowledge of the probability of success with CPR could be used to determine its futility.
For instance, CPR has been shown to have a 0% probability of success in the following clinical circumstances:
Septic shock
Acute stroke
Metastatic cancer
Severe pneumonia
In other clinical situations, survival from CPR is extremely limited:
Hypotension (2% survival)
Renal failure (3%)
AIDS (2%)
Age greater than 70 (4% survival to discharge from hospital)

7. Do-Not-Resuscitate (DNR) orders is creating problems to:
Physicians: not clear on who should be consulted before a DNR decision is written.
House staff and nurses: who are asked to carry on complicated or invasive treatments to patients for whom DNR is written
Health policy makers: who are confused about what their institution policy toward DNR should be.

8. This confusion is mainly due
to failure to distinguish between three distinct rationales for DNR, and
appreciate the various implications tied to their differences.

9. Reasons for DNR could be one or more of the followings:
Request by patient or family
Advanced age
Poor prognosis
Severe brain damage
Extreme suffering or disability in chronically or terminally ill patient
In some instances, the tremendous cost and personnel commitment vs. the probability of patient recovery.
Each reason is good for a certain circumstances but cannot be generalized to all situations.

10. A better approach for decision is to examine each reason against the following distinctive rationales for DNR:
1. No medical benefit (Medical futility).
Physicians have no obligation to provide treatment that is of no demonstrable medical benefits and patients and their families have no right to ask for it.
The imagination of Patients or their families that a futile treatment would be beneficial does not give them the right to receive this treatment.

11. 2. REACHED HEREPoor Quality of life after CPR
The life after cardiac arrest and subsequent CPR is unacceptable;
might be of little or no benefit to patient (in coma) or
the benefit might outweigh the burdens.
The crucial feature is that the arrest, CPR, or both threaten to change the life from one that minimally acceptable to an unacceptable one. e.g. 2nd arrest if predicted to lead to non-beneficial life.

12. 3. Poor quality of life before CPR
This rationale involves the current quality of life and not the quality of life after the arrest. Patient’s life is judged by him or his family to be unacceptable, e.g. severely incapacitated mentally or physically.

13. The establishment of these rationales has resolved the vagueness that surrounded the proper use of CPR.
Previously, it was approved that “ the purpose of CPR is the prevention of sudden, unexpected death.
CPR is not indicated …in cases of terminally ill where death is not unexpected”.

14. But in certain cases with terminal and irreversible illness, DNR could not be justified only on this base because
CPR would not be futile, and
the patient would judge the quality of life both before and after the arrest to be acceptable.
However, terminally ill patient may be given a DNR order for any of the above rationales once there.

15. Contrasts among the three rationales
Contrasts between the three rationales involve:
Relevance of Patient’s values.
Generalization to other treatment options, beside CPR.

16. In the cases of the first two rationales, the futility or the poor consequences of CPR
justify only
the decision for cardiac arrest and DNR
but does not
extend to other life-threatening events and their treatment (lung infection).

17. In the third rationale (poor quality of life before CPR), the DNR order does not involve only cardiac arrest and CPR.
It is a judgment that death is preferable than continued survival.
Therefore, the same logic that supports DNR also supports any other life-prolonging measure.

18. Implication for other treatment
Patient’s value relevance
Rationale No
No medical benefit
Yes
Poor quality of life after CPR.
Poor quality of life before CPR.

19. Communication with patients and families
Communication is guided by the type of rationale involved:
DNR order due to medical futility:
Communication should aim at securing an understanding of the decision already made based on medical expertise.
Under no circumstances should physicians be rude and ignore the wishes of patients and their families that insist on resuscitation.
The debate here is between the physician’s decision and the right of self determination and patient’s preferences.

20. 2. When one of the quality of life is involved, then DNR order needs permission of patient or family.
It is inappropriate to try to persuade them to agree to DNR order.

21. Communication among physicians and staff
DNR order could be a potential source of misunderstanding among the hospital staff, due to uncertainty regarding the rationale that is being applied.
Example: The case of elderly woman with multiple strokes who had DNR request and had been defibrillated of cardiac arrhythmia but not cardiac arrest.
Consequences:
Family and patient were angry (their request was violated).
Staff divided into two factions.

22. Questions arose:
Is arrhythmia part of cardiac arrest?
Is defibrillation equal to resuscitation?
These questions could be answered only if we know the rationale behind the request for DNR.

23. If the rationale is due to no medical benefit, then arrhythmia is not a cardiac arrest and could be treated more successfully.
If it concerns quality of life after resuscitation, again arrhythmia is not a cardiac arrest and quality of life might be secured after defibrillation.
Only if concern was about quality of life before the attack the defibrillation would not be justified.
Solving of the problem is by writing down a clear-cut order and the rationale behind it, including other treatments if any.

24. Hospital Policy
Some of the DNR policies have been proposed in hospitals such as:
DNR order should have no implication on other treatments that are in use beside CPR.
It did not work, because one of the rationales for DNR that is used the most does have an implication for other treatments and hospital staff tend to take DNR order and generalize it to other treatments.
DNR forms with a list of other optional treatments beside CPR.
In the absence of rationale, there has been a tendency to include automatically the other options when DNR is issued.