Indian Journal of Critical Care Medicine

Register      Login



Volume / Issue

Online First

Related articles

VOLUME 10 , ISSUE 1 ( January, 2006 ) > List of Articles


DNR policies in North America: A procedural morass - resuscitation practices revisited

Vinod K. Puri

Keywords : CPR, DNR, ethics.

Citation Information : Puri VK. DNR policies in North America: A procedural morass - resuscitation practices revisited. Indian J Crit Care Med 2006; 10 (1):35-39.

DOI: 10.4103/0972-5229.24688

License: CC BY-ND 3.0

Published Online: 01-07-2010

Copyright Statement:  Copyright © 2006; The Author(s).


More than twenty-five years have elapsed since the first Do Not Resuscitate (DNR) policies were proposed. A historical review of the application of DNR policies is provided with its rationale and perceived effects. A viewpoint is presented, that acceptance of implied consent for cardiopulmonary resuscitation (CPR) in hospitalized patients was responsible for drawing up of DNR policies. Unfortunately, the principle of informed consent as related to CPR and DNR policies, has had unintended consequences. Practical results do not indicate that medical practices have become more humane. Abuses of the process go beyond matters of style and experience, in communicating with surrogate decision-makers. Instead of generating compassion and respect for the patient, policies may contribute to cynicism and lack of caring amongst physicians. Overly optimistic dependence on advance directives to reform medical practices, appears unjustified. The concept of futility to limit demands for non-beneficial care is examined. It is unlikely that physicians can routinely invoke futility, as an argument to limit treatments. A re-examination of DNR policies as a defense against technologic imperative is warranted.

PDF Share
  1. Snider GL. The DO-Not-Resuscitate Order, ethical and legal imperative or medical decision? Am Rev Respir Dis 1991;143;665-74.
  2. Rabkin MT, Gillerman G, Rice NR. Orders not to resuscitate. N Engl J Med 1976;295;364-6.
  3. Tagge GF, Adier D, Bryan-Brown CW, Shoemaker WC. Relationship of therapy to prognosis in critically ill patients. Crit Care Med 1974;2;61-3.
  4. Grenvik A, Powner DJ, Snyder JV, Jastremski MS, Babcock RA, Loughhead MG. Cessation of therapy in terminal illness and brain death. Crit Care Med 1978,6:284-91.
  5. Danis M, Southerland LI, Garrett JM, Smith JL, Hielema F, Pickard CG, et al. A prospective study of advance directives for life sustaining care. N Engl J Med 1991;324:882-8.
  6. The SUPPORT Principal Investigators: A controlled trial to improve care for seriously ill hospitalized patients. The Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatment (SUPPORT). JAMA 1995;274:1591-8.
  7. Kass LR. Ethical Dilemmas in the care of the ill. What is the patient′s good? JAMA 1980;244:1946-9.
  8. Blackhall LJ. Must we always use CPR? N Engl J Med l 987;317:1281-5.
  9. Tomlinson T, Brody H. Ethics and communication in do-not-resuscitate orders. N Engl J Med 1988;318:43-6.
  10. Tomlinson T, Brody H. Futility and the ethics of resuscitation. JAMA 1990;264:1276-80.
  11. Hackler JC, Hiller FC. Family consent to orders not to resuscitate; reconsidering hospital policy. JAMA 1990;264:128-33.
  12. Puri VK, Weber LJ. Limiting the role of the family in discontinuation of life sustaining treatments. J Med Human 1990;11;91-8.
  13. Scneiderman LJ, Jecker NS, Johnsen AR. Medical futility: Its meaning and ethical implications. Ann Intern Med 1990;112:949-54.
  14. Lantos JD, Singer PA, Walker RM, Gramelspacher GP, Shapiro GR, Sanchez-Gonzalez MA, et al. The illusion of futility in clinical practice. Am J Med 1989;87:81-4.
  15. Troug RD, Brett AS, Frader J. The problem with futility. N Engl J Med 1992;326:1560-4.
  16. Veatch RM, Spicer CM. Medically Futile care: The role of the physician in setting limits. Am J Law Med 1992;18:15-36.
  17. Scofield GR. Is consent useful when resuscitation isn′t? Hasting Cent Rep 1991;21:28-36.
  18. Halevy A, Brody BA. Multi-institution collaborative policy on medical futility. JAMA 1996;276:571-4.
  19. Casarett D, Siegler M. Unilateral do-not-attempt-resuscitation orders and ethics consultation: A case series. Crit Care Med 1999;27:1116-20.
  20. Angell M. The case of Helga Wanglie-a new kind of right to die case. N Engl J Med 1991;325:511-2.
  21. Ackerman F. Significance of a wish. Hast Center Rep 1991;21:27-9.
  22. Danis M, Patrick DL, Southerland LI, Green ML. Patients and families preferences for intensive care. JAMA 1988;260:797-802.
  23. Puri VK. End-of-Life Issues for a modern India-Lessons learnt in the West. Indian J Crit Care Med 2005;9:81-5.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.