A Do Not Resuscitate (DNR) order is a specific medical instruction documented by a physician that directs healthcare providers not to perform cardiopulmonary resuscitation (CPR) if a patient’s breathing or heart stops suddenly. This order prevents the use of chest compressions, artificial ventilation, electric shocks, and certain drugs aimed at restarting heart and lung function. While a technical medical decision, the DNR order is rooted in personal values and concerns about quality of life, leading to complex ethical dilemmas. The order is not a directive to withhold all medical care; rather, comfort measures and other treatments will still be provided. DNR orders represent a formal boundary on life-sustaining treatment, generally used when a patient is seriously ill or near the end of life.
The Foundation of Patient Autonomy
The primary ethical principle supporting DNR orders is patient autonomy—the right of a competent individual to self-determination regarding their medical care. Patients have the authority to accept or refuse any medical treatment. A DNR order requires informed consent; the patient must understand their condition, the low success rate and harms of CPR, and alternatives to resuscitation. CPR consent is presumed in an emergency unless a DNR order is actively in place.
An informed discussion must outline the expected outcomes of CPR, which are often poor for patients with severe underlying illnesses and extremely low survival rates. The patient must possess decision-making capacity: the ability to understand information, appreciate consequences, and communicate a consistent decision.
Patients with capacity can document their wishes through advance directives or living wills. These documents ensure preferences are honored even if capacity is lost, upholding prospective autonomy. The ethical obligation is to respect the patient’s decision, ensuring physician bias does not obstruct the choice. The patient retains the right to revoke their DNR order at any time.
Ethical Challenges in Surrogate Decision-Making
Ethical complexity increases when a patient lacks the capacity to make their own DNR decision, necessitating a surrogate decision-maker. Surrogates must follow a hierarchy of decision-making standards. The first is “Substituted Judgment,” requiring the surrogate to make the decision the patient would have made if competent, relying on known wishes and preferences.
When the patient’s wishes are unknown, the surrogate must turn to the “Best Interest” standard. This standard requires choosing the option that promotes the patient’s overall well-being, focusing on the most benefit and the least harm, including dignity. This shift introduces subjectivity and can create ethical tension, often arising when family members disagree about the patient’s prognosis.
Conflicts arise when a surrogate insists on resuscitation despite the medical team’s consensus that such efforts are inappropriate. The physician facilitates discussion and provides clear information about the patient’s condition. The final decision regarding the DNR order, absent medical futility, rests with the surrogate. Ethics committees may be required to mediate these conflicts.
Physician Responsibility and Medical Futility
Physicians face ethical obligations that conflict with patient or surrogate requests, particularly concerning “medical futility.” Futility is defined as an intervention that cannot reasonably achieve the intended physiological goal. If a physician determines that CPR offers no physiological benefit—such as when a patient has multi-organ failure and a near-zero chance of survival—they are not ethically required to provide that intervention.
This determination is grounded in non-maleficence (the duty to avoid harm) and beneficence (the duty to act in the patient’s best interest). Performing futile CPR prolongs suffering, causes physical trauma, and consumes resources without achieving a meaningful outcome. The ethical conflict arises when a family demands full resuscitation despite being informed of the treatment’s lack of benefit.
The physician must balance respect for autonomy with professional judgment and the duty to provide appropriate care. Physicians are not obligated to provide scientifically inappropriate treatment simply because it is requested. Ethics committee review may resolve disputes, and in rare circumstances, the physician may be supported in writing a unilateral DNR order.
The Ethical Requirement for Order Review
A DNR order is not a static decision but a dynamic one requiring regular review and reassessment. Since the patient’s clinical condition, prognosis, and goals of care are subject to change, the DNR order must always reflect the current situation, especially if health improves or new treatments become available.
Healthcare facilities have an obligation to ensure the order is periodically discussed with the patient or their surrogate. This reassessment confirms that the DNR status still aligns with the patient’s wishes and the medical reality. A patient with decision-making capacity retains the right to revoke a DNR order at any time, and the healthcare team must promptly document and implement the revocation.