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Despite the extensive literature devoted to do-not-resuscitate (DNR) orders, they continue to raise vexing problems for physicians, house staff, nurses, and policy makers. The difficulties include physicians' ambivalence about who should be consulted before a DNR order is written, the frustration of house officers and nurses who are asked to continue complicated or invasive treatments of a patient for whom a DNR order has been written, and hospital administrators' uncertainty and confusion over what their DNR policies should be.
Many of these problems arise from the failure to distinguish among three distinct rationales for DNR orders and to appreciate their differing implications. Although some commentators, notably Annas,1 have insisted that different justifications for a DNR order should be explicitly distinguished, the majority view has lumped them all together uncritically:
A decision not to resuscitate is considered for a variety of reasons: a request by a patient or family; advanced age of the patient; poor prognosis; severe brain damage; extreme suffering or disability in a chronically or terminally ill patient; and in some instances, the enormous cost and personnel commitment as opposed to the low probability of patient recovery.
Each of the reasons listed may be good in one circumstance or another. But this shopping-list approach hides important differences among three distinct rationales that need to be better articulated and understood.
Three Rationales for DNR
No Medical Benefit
A commonly accepted ethical principle is that physicians have no obligation to provide, and patients and families have no right to demand, medical treatment that is of no demonstrable benefit.3 Patients or families may wrongly imagine that a futile treatment would be beneficial, but this imagined benefit does not generate a right to receive treatment; otherwise, patients would be entitled to demand and receive laetrile and other quack therapies from their physicians.4
Although published data on survival after cardiopulmonary resuscitation (CPR) will not always be decisive in individual cases,5, 6 we believe there are circumstances when a DNR order is justified because resuscitation would almost certainly not be successful, and so would be of no benefit to the patient. This rationale for DNR orders has been discussed by Blackhall.7
Poor Quality of Life after CPR
A second reason for withholding CPR is that the quality of life...