Fifty-two year old Jill Baker, who has cancer, was alarmed to discover a ‘do not resuscitate’ (DNR) order on her notes during treatment for septicaemia. She had no idea it had been put in place. [1] In the last year, Age Concern, a group concerned with the rights of older people, has compiled a list of 50 similar complaints from elderly patients whose notes had been labelled ‘DNR’ without consultation with either themselves or their families. [2]

What are DNR orders?

DNR orders apply to the situation of cardiac or respiratory arrest, where cardio-pulmonary resuscitation (CPR) is considered necessary to save life. If a patient is designated ‘DNR’, CPR is withheld, allowing them to die without a resuscitation attempt. DNR orders relate only to CPR and should not affect other treatments. [3]

Current problems with DNR orders

Lack of consultation over instituting DNR orders is a well-publicised problem and there are two other areas of concern. First, patients with DNR orders are 30 times more likely to die; independent of prognosis, disease severity, age or other confounding factors. [4] This suggests that the letters ‘DNR’ influence decisions about treatments other than resuscitation. Second, in deciding which patients should be considered for DNR orders, the way is open for hidden prejudices to creep into decision-making. Older people, ethnic minorities, people who do not speak English, alcoholics and HIV positive patients receive DNR orders more often than other groups of patients. [4] These examples of injustice raise worrying questions.

When is a DNR order appropriate?

Under the 1999 resuscitation guidelines (issued by the BMA, the Royal College of Nurses and the Resuscitation Council) DNR orders are considered appropriate when CPR is:

1. unlikely to be successful
2. unlikely to have an outcome which is acceptable to the patient
3. not wanted by a mentally competent patient

Determining the likely outcome of CPR in the event of an arrest requires sound clinical judgement and is the role of the doctor at the head of the team involved. The assessment should be done prior to an emergency situation. [3,5]

Assessing the likely quality of life after CPR is, however, not an area where doctors necessarily have special expertise, as it requires value judgements relating to more than just the patient’s physical state. [5] Discussion with the patient and family as to their wishes is very important and most patients want to be involved in making the decision.[4] The BMA guidelines suggest that doctors inform patients carefully of their reasons for suggesting a DNR order and then listen to the opinions of all involved.[3] However, there are no legally binding requirements for this. Currently, the recommendations are not being followed consistently and many patients are not even being informed that they have been designated ‘DNR’.[1,2] This is unacceptable practice.

How should Christian medics respond?

The scriptural accounts of Jesus’ life show us that we should not always give in to death. Jesus felt the pain of death and he sometimes took action to reverse it. He raised Lazarus from the grave (Jn 11:43-44), revived Jairus’ daughter (Lk 8:54) and brought to life the dead son of a widow (Lk 7:14). We too should assert the value of life and relieve unnecessary loss by using our skills to prevent death where it is not inevitable or timely.

However, we also know that ultimately death must come to every human being as a result of the fall (Gn 3:19, Rom 4:12-14). There is a ‘time to die’ (Ec 3:2). God is sovereign, we cannot always prevent death. This is reflected in the statistics for outcomes after CPR is initiated: overall survival to hospital discharge is only 20%. [6] An attempt at resuscitation often represents a futile imposition of further suffering on the patient and their family and robs them of a peaceful death. Out of respect for our patients’ dignity, it may well be appropriate to offer a DNR order to those patients for whom resuscitation is thought unlikely to be successful. However, we should do so with careful judgement.

DNR decisions should be implemented only when clinically relevant and only after proper discussion, if possible, with the patient and their loved ones. Specific guidelines need to be developed and applied to reduce the influence of hidden prejudices over the process. We should also ensure that any patient given a DNR order continues to receive the highest quality of care in other areas of their management. Even as students we can raise these issues for discussion and point out breaches of the guidelines that are already in place. Above all we must show in our actions our belief in God’s compassion as well as our respect for his sovereignty.