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Later Than Sooner: A Proposal for Ending the Stigma of Premature Do‐Not‐Resuscitate Orders

The case and analysis by Abadir and colleagues presents a perceptive depiction of a patient’s last days, during which she received aggressive therapy despite an advance directive (AD) indicating wishes to the contrary. Their contribution, which adds to the growing body of literature describing the failure of the AD to improve care, demonstrates how the AD can create misunderstandings and distrust that, although extreme in this case, are more generally symptomatic of its underlying structure built on the foundation of the resuscitation question. This question, concerning the treatment of future cardiac arrest, evolved at a pivotal crossroads in the history of medicine and the development of its relationship to the technology of lifesustaining treatments and the movement to involve patients in decision-making about their future. Because of their important historical context, the therapy of cardiopulmonary resuscitation (CPR) and the order to forgo it, the do-not-resuscitate (DNR) order, have taken on a constellation of important symbolic meanings that are often different for patients, their families, and the healthcare team. These disparate meanings can then serve to hijack discourse about prognosis and the possibility of actual therapies, in this case a potentially therapeutic trial of intubation that required a thoughtful weighing of burdens and benefits, and instead encourage an all-or-nothing approach informed by the hypothetical of future resuscitation. In a previous editorial in this journal and elsewhere, I called for a reconsideration of the default application of CPR, which would make the DNR order obsolete, but because of the significant history of CPR and the DNR order, this eventuality remains far off. In following the highly endorsed practice of establishing the DNR order far in advance and vividly depicting the resultant contentious outcome, this case suggests a procedural shift that holds the promise of diminishing the symbolic power of DNR and CPR and their malignant effect on discourse—the relocation of the resuscitation question to later in care, not sooner! A brief review of the significant history of CPR, DNR, and the AD can offer insight into their contemporary meanings and practice. Soon after the DNR order was established as the first codified limitation of therapy and a call for patients and families to make the decision, the states, beginning with California in 1977, created Natural Death Acts to establish the legality of living wills so that patients could make this decision in advance. The desire to respect autonomy and involve patients while they still possess decision-making capacity led to the call for initiating discussions about the termination of treatment when patients are first diagnosed with potentially terminal conditions. In response to the rare use of living wills, their vague language and emphasis on stopping therapies, the “medical directive,” which laid out a series of potential future scenarios and interventions, was proposed in 1989. Respecting its history as the first “life-prolonging” therapy decision to be made in advance and perhaps because of the implications of that decision, the medical directive and all subsequent ADs list the CPR question as the first choice to be made. The new proposed health reform law, promising incentives for doctors engaging in AD discussions as part of a clinic visit, will potentially move the DNR question to an even earlier point in patients’ lives. From early in its history, there was some awareness that the meaning and implications of the DNR order would be broader than simply not performing CPR in the event of cardiac arrest. The indication to perform CPR in the hospital was evolving even before the technique was established in the 1960s, when open cardiac massage was the procedure of choice, and “death” was stipulated as the indication. Given this indication, it is not surprising that the order to withhold this treatment would carry meanings about impending death and helps explain why the DNR order is written mostly for patients who are expected to die soon, despite substantial efforts to the contrary. When the President’s Commission on Ethics directed that “any DNR policy should ensure that the order not to resuscitate has no implications for any other treatment decisions” in 1983, it expressed an aspiration that transcended the power of policy, as indicated by later empirical evidence— that the DNR order had other important implications. Despite its compelling history and evidence to the contrary, many still faithfully insist that DNR means only forgoing resuscitation. Moving the AD decision earlier means that the question of the desirability of future CPR, a question rich in historical symbolic meanings and implications, will be used as an organizing principle for difficult discussions about negotiating future care with patients who are not dying, at least not in the near future. An irony of this practice is that CPR is largely impotent as a therapy to substantially alter most disease trajectories. Most other therapeutic decisions that arise in the course of a patient’s illness are much more important for patients and families than future CPR. DOI: 10.1111/j.1532-5415.2011.03701.x