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SPECIAL ARTICLE

Ethical Challenges of Partial Do-Not-Resuscitate


(DNR) Orders
Placing DNR Orders in the Context of a Life-Threatening Conditions Care Plan
Jeffrey T. Berger, MD

o-not-resuscitate (DNR) orders are commonly found in treatment plans for patients near
the end of life. Orders for partial resuscitation (eg, do not intubate) have evolved from
DNR orders. Although the ethics of DNR orders have been widely examined in the medical literature, little has been written about the ethics of partial resuscitation. This article
explores the ethical implications of partial DNR orders and identifies the need to develop care plans
addressing life-threatening conditions for patients with DNR orders.
Arch Intern Med. 2003;163:2270-2275
Do-not-resuscitate (DNR) orders prohibit the use of interventions to reverse a
cardiac or pulmonary arrest.1-5 Typically,
these orders refer to the entire range of resuscitative efforts including basic life support and advanced cardiac life support.
Writing formal DNR orders is a relatively
new practice, having first appeared in
the MEDLINE-referenced literature in
the early 1980s.6,7 Orders for partial DNR
(eg, cardiac DNR or do-not-intubate orders) have more recently entered the
hospital vernacular and are directives
through which a patient receives some,
but not all, of the discrete elements of cardiopulmonary resuscitation (CPR).8-11 For
example, a do-not-intubate order permits cardiac resuscitation but prohibits endotracheal intubation for cardiopulmonary arrest. A chemical code refers to
resuscitative attempts limited to the use
of medications.10,12 Of all DNR orders,
probably fewer than 10% stipulate limited resuscitation.13 Limited data that are
available evidence dismal survival rates
among recipients of partial resuscitation.13 This finding is expected, given the
well-established relationship between rapidity of successful resuscitation and
clinical outcomes.14-18 Order writing for
this often ineffective treatment has gen-

From Winthrop University Hospital, Mineola, NY, and State University of New York,
Stony Brook School of Medicine, Stony Brook. The author has no relevant financial
interest in this article.
(REPRINTED) ARCH INTERN MED/ VOL 163, OCT 27, 2003
2270

erated only limited attention to the use


of, and ethical issues associated with,
partial resuscitation.8,19,20 In contrast,
slow codes are CPR protocols applied
with suboptimal effort and without resuscitative intent. Slow codes are medically and ethically inappropriate and are
not discussed here.
Medical and bioethics organizations
have generated a broad consensus on the
ethical the use of DNR orders.1-5 However, these organizations offer scant guidance on the use of partial DNR orders. Reports on the ethical use of CPR by the
Council on Ethical and Judicial Affairs of
the American Medical Association and by
the American College of Physicians make
no reference to these orders.2,3 The New
York State Task Force on Life and the Law
refers to partial DNR orders, but makes no
comment on their appropriate use.1 The
Hastings Center and the American Heart
Association both suggest that partial resuscitation may be appropriate, albeit
rarely, when requested by an informed patient or surrogate. However, neither organization explicates an ethical rationale
for this position.4,5
Much is unknown regarding the
prevalence or use of the various types of
partial DNR orders. Also not known is the
degree to which patients or family members consent to partial DNR orders are informed, although data suggest that patients are often not well informed regarding

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DNR decisions.21-23 No studies describe physicians motivation, intent, or expectations for outcome
when these physicians authorize partial resuscitation. We do not know
who among physicians, patients, and
families advocate for partial DNR orders rather than full DNR orders. Although the presence of a DNR order tends to influence clinical
approaches to nonarrest conditions,24-27 it is unclear how physicians define the scope and utility of
full and partial DNR orders.
USE OF PARTIAL DNR ORDERS
Partial DNR orders affect treatment
of actual cardiopulmonary arrests as
well as treatment of life-threatening nonarrest conditions, for which
only some intensive interventions
are desired. In either case, partial
DNR orders are often clinically perplexing and ethically problematic.
Partial DNR Orders
to Direct Care for Cardiac or
Pulmonary Arrests
With only particular exception, partial attempts to reverse a cardiac or
pulmonary arrest are medically unsound because these interventions
are often highly traumatic and consistently inefficacious.13 Partial resuscitation generally violates ethical obligations of nonmaleficence,
that is, to avoid disproportionate patient harms.28 Rarely, cardiac resuscitation alone, written as pulmonary DNR or do-not-intubate
orders, may be appropriate when
cardiac and respiratory arrests are
pathophysiologically distinct and
prognosis is good with cardiac resuscitation alone. For example, malignant arrhythmias in the perimyocardial infarction period may be
quickly and successfully treated with
electrical cardioversion before the
airway can be, or needs to be, secured by intubation. Patients who
wish never to be intubated may accept this plan. This treatment is ethically supportable because it is reasonably efficacious in meeting a
medically acceptable, patientdefined care goal.
Respiratory resuscitation alone,
written as cardiac DNR, is generally inappropriate for cardiopulmo-

nary arrest because oxygenating a


patient without circulation is physiologically pointless, invasive, and
traumatic and again violates nonmaleficent obligations. Cardiac DNR
orders are sometimes written for already intubated patients with the intent of not prohibiting reintubation for respiratory insufficiency.
Respiratory resuscitation alone may
be appropriate in situations when
respiratory arrest occurs distinct
from a cardiac arrest and the treatment is reasonably efficacious in
meeting a medically acceptable,
patient-defined care goal (eg, intubation for asthmatic exacerbation
or aspiration of foreign body). Another example is when an intubated patient with a DNR order,
found self-extubated, experiences
a respiratory arrest, but not yet a
cardiac arrest, and continued mechanical ventilation is appropriate
to support recovery from an acute
illness.
Most cardiac or pulmonary arrests fall outside of these clearly defined clinical scenarios when partial resuscitation is medically
appropriate. Physicians should rarely
write partial DNR orders, and then
only after identifying clear treatment objectives collaboratively with
the patient.
Partial DNR Orders
to Direct Care for
Life-Threatening Conditions
Hospitalized patients with DNR orders often develop life-threatening
conditions. 29 Frequently, physicians are uncertain as to how and to
what degree they should treat these
conditions. There is poor agreement among clinicians regarding
how a DNR order should influence
treatment for nonarrest but lifethreatening states.9,19,24,30 Parenthetically, several other medical and nonmedical variables may influence this
care including physician specialty
and religion.31-36
In fact, DNR orders are not intended to govern pre-arrest care. By
definition, DNR orders apply specifically to states of cardiac or pulmonary arrest and do not directly illuminate care plans or patients
preferences for treatment except for
states of cardiopulmonary arrest. Pa-

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2271

tients considerations underlying their


decisions for no resuscitation may, but
not necessarily, support nontreatment of life-threatening states.37 For
example, a patient may decline CPR
for arrest conditions but may readily
agree to mechanical ventilation for a
likely reversible pneumonia. Do-notresuscitate orders, designed as highly
circumscribed clinical directives, are
commonly misapplied to pre-arrest
care.24,27,38,39 There are several possible reasons for this imprecise use of
DNR orders. First, DNR orders do not
accommodate the clinical reality that
pre-arrest states and arrest states often sit along a continuum of physiologic derangement. For example, a
patient with stable ventricular tachycardia is not considered arrested. At
some point, as falling blood pressure
leads to increasingly clinically apparent organ hypoperfusion, the patient is diagnosed with cardiac arrest. At what point does the DNR
order become determinative regarding medical response?
Second, physicians may overrely on DNR orders because these
discussions about CPR are usually
more limited and therefore more
manageable compared with the
broader, more complex, and more
nuanced conversations about care
goals often required in developing
overall treatment plans for patients
with DNR orders.40 In fact, goals of
care are important, yet they are generally absent or underemphasized in
advance health planning.41-43
Third, DNR orders are concrete action guides for specific clinical conditions. This clarity highlights the absence of similarly clear
and readily interpretable directives
for the treatment of a myriad of nonarrest but life-threatening conditions.44-46 Clinicians may use DNR
orders to fill this vacancy. The explicitness of DNR orders, the challenges of discussions about goals of
care, and clinical ambiguities determining the onset of arrest entice clinicians to broaden the use of DNR
orders, as manifest in partial DNR
orders. However, resuscitation directives serve poorly as broader treatment directives, as the following case
illustrates:
For airway protection, a tracheostomy was placed in a 71-yearold man with congestive heart fail-

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ure and chronic obstructive lung


disease (status: postmandibular resection for localized squamous cell
carcinoma), and he was periodically attached to a mechanical ventilator for episodes of mucous plugging and exacerbations of congestive
heart failure. The patients treatment preferences were primarily
guided by quality-of-life concerns.
He desired every treatment, including mechanical ventilation, if, in his
physicians estimation, the intervention would at least allow him to continue enjoying televised sporting
events. He wished no attempts at cardiac resuscitation because he understood that, given his comorbid
diseases, it would not likely result
in an acceptable quality of life. A no
cardiac resuscitation order was
written so that mechanical ventilation would not be withheld.
Partial DNR orders are seriously limited mechanisms for communicating in the medical record with
other health team members. In this
case, the cardiac DNR order inadequately transmitted the patients
treatment preferences because the order implied use of mechanical ventilation irrespective of both the cause
of respiratory insufficiency and the
likelihood of achieving the patients
treatment goal. Furthermore, a cardiac DNR might be interpreted as prohibiting cardioversion for some nonterminal arrhythmias, irrespective of
likely treatment outcome. Similarly,
an unrestricted DNR order could be
interpreted as categorically precluding all resuscitationlike treatments
that could meet the patients treatment goals, including mechanical
ventilation.
DEVELOPING SUPPLEMENTAL
PATIENT INFORMATION:
CARE PLANS FOR
LIFE-THREATENING
CONDITIONS IN PATIENTS
WITH DNR ORDERS
Treatment plans that include DNR
orders often overlook plans for treating unstable conditions that often
precede frank arrests. Lo47 summarizes the clinical ambiguities created by DNR orders:
First, the same reasons that make CPR inappropriate may also render other treatments unsuitable. Second, for patients in

intensive care settings, the practical question is whether to treat the physiologic abnormalities . . . after a DNR order is written . . . if untreated, these abnormalities
could lead to cardiopulmonary arrest.
Third, informed patients may reject some
forms of . . . life support while accepting
others.

However, neither DNR nor partial DNR orders are intended to communicate complex end-of-life care
plans, and they clarify little about patients goals of care.
Efforts to fill this gap have been
reported. The values history48 assists in recording patients broad
quality-of-life goals but serves poorly
as action guides. Conversely, instruments offering checklists of the discrete elements of CPR are specific action guides.9,49,50 However, they can
facilitate orders for medically unsound treatment compositions (eg,
treating malignant arrhythmias with
chest compressions alone) and are
generally inattentive to goals of
care.51,52 Although these directive
tools may reduce interprofessional
variability regarding treatment of patients with DNR orders, they do not
necessarily promote appropriate
care.
Use of partial DNR orders
should be avoided (no intubation orders may be used to supplement
DNR orders when intubation for
nonarrest respiratory conditions is
also inappropriate). Rather, physicians should collaborate with each
patient or surrogate for whom a DNR
order is written to develop supplemental information supporting a
care plan that addresses treatment of
life-threatening conditions. This care
plan should contain the following 5
elements:
1. Identification of patients
treatment goals: Patients or patients surrogates should describe
their broad health care objectives,
with guidance from their health professionals. Clarification of these goals
is fundamental to developing patient-relevant and medically coherent treatment plans.51 Patients who
consent to DNR orders may define
goals of care as symptom palliation
alone; the pursuit or maintenance of
a specific quality of life (commonly
determined by a particular cognitive or functional ability); or as preservation of life regardless of qual-

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ity. These goals often obligate


physicians to withhold some medically indicated interventions. Alternatively, patients whose are goals are
unattainable or unreasonable, particularly in light of plans for no resuscitative attempts, may benefit
from additional dialogue with health
professionals to form realistic and
meaningful care objectives.
2. Information developed includes identifying specific medical interventions declined by the patient or
surrogate: Patients or patients surrogates may proscribe certain interventions despite fair likelihood that
these interventions may achieve a
patient-defined goal of care. Patients may refuse interventions because of excessive attendant burden or discomfort or because of
some subjective objection. For example, a patient with a DNR order
has identified her care goal as continued survival as long as she can
recognize family members. However, she may refuse hemodialysis for
any condition, even reversible ones,
because of quality-of-life costs. Some
patients or their surrogates know
clearly what interventions they wish
to restrict well in advance of a lifethreatening condition.
3. Care plan allows for physician judgment and discretion in
determining the utility of specific treatments in particular clinical circumstances within the context of patients
care objectives: Physician judgment is
indispensable to maximize patient
benefit and minimize patient harms,
particularly in urgent clinical situations. Physician discretion must
closely adhere to reasonable medical
judgment and must attend, with great
fidelity, to patients defined goals of
care. Discretion must be repeatedly
and frequently informed by discussions with the patient or surrogate in
terms of thresholds for treatmentassociated burdens and tolerance for
probabilities of outcome. For example, the patient described above develops urosepsis and hypotension.
Her physician orders antibiotics and
intravenous pressor medications because achieving her care goal of recovering to a fair state of cognition is
still probable. She then develops ischemic acute tubular necrosis, renal
failure, and altered mental state. The
probability of meeting her care goals

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Elements of a Life-Threatening Conditions Care Plan


Element

Purpose

Description/Example

1. Patient goals

To assist the patient in clearly identifying his or her


broad purpose for treatment.

2. Refusal of specific interventions

To allow patients to specify interventions that are


objectionable, irrespective of treatment efficacy.

3. Physician discretion

To apply physician expertise and judgment to the


pursuit of patients treatment objectives.

4. Correlate goals with interventions

To ensure medically sound treatment plans,


particularly when patients requests for specific
treatments may be medically inappropriate.

5. Easily transmittable

To make available essential information to guide staff


in urgent responses to life-threatening conditions.

are now considerably lower, and dialogue between the physician the surrogate is needed to assess how evolving probabilities of outcome intersects
with changing treatment-associated
burdens.
4. Care plan must link patients
or surrogates requests for specific treatments to goals of care to avoid medically inappropriate combinations of
medical interventions: Patients or surrogates particular requests for endof-life treatments sometimes may be
unsound (eg, declining dialysis for
acute renal failure but requesting mechanical ventilation for the consequent acidosis-induced tachypnea).
These treatment declination/request
associations must correlate with the
patients goal of care so that treatment remains patient centered and
not misdirected by social, emotional, or other concerns.
5. Care plan must be easily interpretable by any physician likely to
be a first responder to a medical emergency: A great challenge is how to reliably and clearly transmit through the
medical record nuanced discussions
of end-of-life care preferences so that
first responses to life-threatening conditions in patients with DNR orders
are consistently appropriate. Any care
plan must be easily interpretable to
guide emergent action until attending physicians are available to impart judgment over treatment choices.
For example, a care plan should

Preservation of defined cognitive or functional status;


symptom palliative alone; survival regardless of
quality of life.
Patients may refuse interventions because of
excessive attendant discomfort or burden, or
because of some subjective objection. Patients may
refuse highly useful interventions, such as feeding
tubes or hemodialysis, on these grounds.
The physician, while integrating rapidly changing
clinical parameters, selects interventions
appropriate to the patients goals of care.
Requests for specific treatment should be measured
against identified goals for care. For example, a
patient request for cardiac but not pulmonary
resuscitation should trigger a discussion of
treatment efficacy relative to the treatment goal.
By defining categories of care objectives (palliation,
survival at all costs short of cardiac or pulmonary
resuscitation, defined functional/cognitive status)
and by allowing patient refusal of specific
treatments, first responders are better positioned to
provide appropriate emergent care.

clarify whether a patient with a DNR


order should be intubated for nonarrest respiratory conditions (Table).
LIMITATIONS AND
CONCERNS
A conceptual problem surrounding
peri-arrest care is the persistent notion among professionals that, in
terms of medical decision making and
ethical obligations, CPR for arrest
states is substantively different from
other treatments for other lifethreatening conditions. In fact, the
major difference between arrest and
nonarrest states is the temporal relationship between treatment and result, and this difference is not ethically germane. For example, some
nonarrest conditions are more lethal
than some arrest states (eg, sepsis
compared with ventricular tachycardia arrest in acute myocardial
infarction).53,54 Meaningful distinctions rely not on whether circulation or respiration have ceased, but
whether achievable treatment results are clinically significant and valuable to the patient. A conceptually integrated clinical approach involves
broader goal-oriented conversations
with patients that incorporate, within
a dialogue of disease and prognosis,
discussions about goals of care for cardiopulmonary arrest.
Prevailing medical culture
holds other obstacles to improving

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care of patients near the end of life.


Cornerstone tasks include improving patient-professional communication, treating pervasive discomfort with death and dying, and
changing corporate culture so that
dying well becomes more widely accepted as a serious obligation, particularly in acute care hospitals. In
the context of this culture, DNR orders may provide false refuge for
physicians and other professionals
seeking clear and fixed care plans for
dying patients whose often shifting
needs demand fluidity of thinking
and subtlety of response.
A shift from interventionoriented care toward goal-oriented
care requires attention to some practical issues. Treatment limitation
forms should be revisited. These
forms should be revised as treatment guide for life-threatening conditions forms and should supplement all DNR orders. These forms
should be constructed to serve as
structured progress notes wherein
physicians can clarify, document, and
communicate patients goals of care.
A model document that incorporates the 5 elements discussed earlier is suggested in the Figure. Still,
other practical, logistical, and system issues remain, such as time constraints, improving physicians communication skills, educating the
public and counseling patients and
their likely surrogates regarding end-

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TREATMENT GUIDE FOR LIFE-THREATENING CONDITIONS IN


ADULT PATIENTS WITH DNR ORDERS
Cardiac or pulmonary resuscitation (CPR), or portions of CPR (aka, partial DNR, DNI),
will not be used in the event of a cardiac or pulmonary arrest, consistent with the DNR order.
The physicians of_______________________, using reasonable medical judgment, and limited by
patient/family consent, will treat LIFE-THREATENING CONDITIONS, short of a cardiac or pulmonary arrest
(eg, hypotension, GI bleeding, respiratory distress), consistent with the patient/familys treatment goals
identified below [SELECT A, B, or C]:

arrest conditions (eg, pneumonia,


congestive heart failure, and chronic
obstructive pulmonary disease exacerbations), but who wish no resuscitation, a DNR order should be entered into the medical record.
Education is needed to clarify the appropriate and limited scope of DNR
orders.

____ A. GOAL OF CARE IS CONTINUED PATIENT SURVIVAL, regardless of anticipated cognitive/functional


outcome. All medically appropriate interventions, excluding CPR, should be used in pursuit of this
goal (eg, IV pressors, intubation for nonarrest conditions).
or
____ B. GOAL OF CARE IS SYMPTOM PALLIATION ONLY. The patient will not receive interventions intended
to extend the patients life, including all items listed in C2 below.
or
____ C. GOAL OF CARE IS TO ACHIEVE/PRESERVE THE COGNITIVE STATUS OR FUNCTIONAL STATUS
SPECIFIED BELOW. [COMPLETE SECTIONS 1 AND 2 BELOW]
1. Indicates goals of care from one or both categories.
Cognitive status defined as at least:
____ Arousable
____ Awake but confused
____ Alert and largely oriented to person/place/time
Functional status defined as at least:
____ Bedbound/chairbound
____ Ambulatory with assist/devices
2. The following interventions should be offered only if, in physician judgment, they are likely to
achieve the above treatment goal. However, the patient/surrogate may refuse specific interventions
regardless of the potential treatment efficacy. Indicate intervention(s) that the patient/surrogate
definitely declined.
Interventions definitely declined:
____ Endotracheal intubation
____ IVF boluses for BP support
____ IV pressor medications
____ IV antiarrhythmic medications
____ Electrical cardioversion (nonmalignant arrhythmia)
____ Blood or blood products
____ Acute hemodialysis
____ Cardiac pacemaker
____ CPAP/BiPAP ventilation
*If not declined, actual use of each intervention must: (1) relate to specific goals of care; (2) follow burden/benefit
discussions; and (3) follow usual process for informed consent

Medical attending signature after content discussed with patient/surrogate


_____________________________________________________________
_____________________________________________________________

Date (review weekly)


_________________
_________________

Model do-not-resuscitate supplemental document. BiPAP indicates bilevel positive airway pressure;
BP, blood pressure; CPAP, continuous positive airway pressure; DNI, do not intubate; DNR, do not
resuscitate; GI, gastrointestional; IV, intravenous; IVF, intravenous fluids.

of-life care before critical illness


strikes. Regardless, peri-arrest care is
an important issue in need of ongoing attention.
SUMMARY
Discussions of CPR should be integrated into the larger conversation of
treatments for life-threatening conditions so that care plans for the end
of life are broader and seamless.
Supplemental care plans are needed
to assist clinicians in appropriately responding to life-threatening conditions that develop in patients with

DNR orders. Partial resuscitation


should be avoided except when the
patient or surrogate, together with the
physician, can define a clear, medically reasonable objective that can be
met with partial resuscitation that
does not cause disproportionate suffering to the patient. No intubation orders should be used only to supplement DNR orders unless the
previously stated conditions are met.
These patients should also be assisted in clarifying whether they wish
to avoid any intubation or only longterm intubation. For patients who desire mechanical ventilation for non-

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CONCLUSIONS
Orders for partial resuscitation are
often confusing and deficient plans
for care. Care plans specifically guiding care for life-threatening conditions should be developed for all patients with DNR orders. These plans
should incorporate patients goals of
care, provide for patient refusal of
specific treatments, allow for physician discretion, reconcile requests for specific treatments with
care goals, and be readily interpretable. Successful implementation of
such care plans will require an
evolved paradigm of care in which
both patients and physicians are
more meaningfully empowered in
their partnering and in which the
health system allows patients, families, and professionals to recognize
and embrace timely deaths.
Accepted for publication December 17,
2002.
The author recognizes Gerald
Brody, MD, Anne Bantleon, RN, and
other members of the Winthrop
University Hospital Bioethics Committee for their collaboration in the
development of the model do-notresuscitate document.
Corresponding author and reprints: Jeffrey T. Berger, MD, 222 Station Plaza N, Suite 518, Mineola, NY
11501 (e mail: jberger@winthrop.org).
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