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CPR for Patients Labeled DNR: The Role of the Limited Aggressive Therapy Order

Niteesh K. Choudhry, MD, FRCPC; Sujit Choudhry, LLB, LLM; and Peter A. Singer, MD, MPH, FRCPC
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From Harvard University, Cambridge, Massachusetts; and University of Toronto, Toronto, Ontario, Canada.

Acknowledgments: The authors thank Dan Sulmasy and Alvin Moss for helpful comments on an earlier draft of the manuscript.

Grant Support: Dr. N.K. Choudhry received the K.J.R. Wightman Award for Research in Biomedical Ethics from the Royal College of Physicians and Surgeons of Canada for this manuscript. He was also supported by a Frank Knox Scholarship from Harvard University and a Canadian Institutes of Health Research Post-Doctoral Fellowship. Professor S. Choudhry was supported by a Graduate Fellowship from the Harvard University Center for Ethics and the Professions and a Connaught New Staff Grant from the University of Toronto. Dr. Singer is supported by a Canadian Institutes of Health Research Investigator award and the University of Toronto Sun Life Financial Chair of Bioethics.

Requests for Single Reprints: Peter A. Singer, MD, MPH, FRCPC, University of Toronto, 88 College Street, Toronto, Ontario M5G 1L4, Canada.

Current Author Addresses: Dr. Choudhry: Toronto General Hospital, Eaton North, Ground Floor-246, 200 Elizabeth Street, Toronto, Onatario M5G 2C4, Canada.

Mr. Choudhry: Faculty of Law, University of Toronto, 78 Queen's Park, Toronto, Ontario M5S 2C5, Canada.

Dr. Singer: University of Toronto Joint Centre for Bioethics, 88 College Street, Toronto, Ontario M5G 1L4, Canada

Ann Intern Med. 2003;138(1):65-68. doi:10.7326/0003-4819-138-1-200301070-00014
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Patients who sustain a cardiac arrest have a less than 20% chance of surviving to hospital discharge. Patients may request do-not-resuscitate (DNR) orders if they believe that their chances for a meaningful recovery after cardiopulmonary arrest are low. However, in some identifiable circumstances, cardiopulmonary resuscitation (CPR) has a higher chance of success and lower likelihood of neurologic impairment. The probability of survival from a cardiac arrest influences patients' wishes regarding resuscitation; thus, when CPR has a higher likelihood of success, patients' expressed preferences for treatment as contained within a DNR order may not accurately reflect their intended goals. Patients should be offered the option of consenting to CPR for higher-success situations, including a witnessed cardiopulmonary arrest in which the initial cardiac rhythm is ventricular tachycardia or fibrillation, cardiac arrest in the operating room, and cardiac arrest resulting from a readily identifiable iatrogenic cause. This new level of resuscitation could be called a limited aggressive therapy order.





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