Impediments to Writing Do-Not-Resuscitate Orders

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Abstract
SINCE THE 1960s, American hospitals have had standing orders for medical personnel to initiate cardiopulmonary resuscitation (CPR) and call for emergency resuscitation upon the discovery of a patient who is pulseless or apneic.1 This requirement made no exceptions for the patient's underlying disease process or prognosis. During the 1970s, hospital regulations evolved to incorporate the moral principle of patient autonomy.2 Patients could request that CPR and other aggressive medical modalities not be initiated. Physicians would implement such a patient request by writing an order not to resuscitate the patient (a do-not-resuscitate [DNR] order).3 Furthermore, physicians have been exhorted to educate patients about the realities of their illnesses and to encourage acceptance of the physician's recommendation to forego aggressive medical interventions at the end of life.4,5 These changes in practice appeal to common sense and are widely accepted. These principles have been clearly supported by consensus statements from major medical societies6-10 and other organizations11,12 and have been codified in the Patient Self-determination Act of 1990.13