Do Not Resuscitate (DNR) Orders

Maddie Sacchiero
Dr. Timothy Kelly
Gettysburg College Health Science Department
April 30, 2024
 Do Not Resuscitate (DNR) Orders

Do Not Resuscitate (DNR) orders are critical directives in healthcare, primarily utilized

in the context of end-of-life care. They are formal instructions that healthcare providers

recognize and follow, indicating that cardiopulmonary resuscitation (CPR) or other life-

sustaining interventions should not be performed if an individual's heart stops beating or if they

stop breathing. The purpose of a DNR order is to respect the patient's wishes regarding medical

treatment at the end of their life.

DNR orders are typically instituted as part of advance care planning, which involves

discussing and documenting preferences for medical care in anticipation of a situation where a

person might not be able to communicate their wishes directly due to severe illness or

incapacitation. These discussions often include the patient, their family members, healthcare

proxies, or surrogates—designated individuals who make decisions on behalf of the patient if

they are unable to do so themselves.

The decision to implement a DNR order can stem from various considerations, including

the patient’s values, quality of life expectations, the likelihood of recovery, and medical advice

from healthcare professionals. For patients with terminal illnesses, chronic debilitating diseases,

or in conditions where recovery is unlikely and the quality of life would be severely

compromised, a DNR order helps ensure that medical treatment aligns with their preferences.

Moreover, DNR orders also alleviate the emotional and physical burden on patients and their

families by preventing potentially invasive and distressing medical interventions that may

prolong suffering without a significant improvement in health outcomes. By clarifying these

critical decisions in advance, DNR orders contribute to more dignified and compassionate end-

of-life care.
 The origin and ethical implications of Do Not Resuscitate (DNR) orders, such as patient

autonomy, quality of life after CPR is preformed, and the communication that goes on before the

fact, are deeply entwined with the evolution of cardiopulmonary resuscitation (CPR) techniques

and their application across various medical contexts. Introduced in the 1960s, CPR represented

a significant advancement in emergency medical care, initially intended for sudden, unexpected

cardiac arrests in otherwise healthy individuals. Over time, the application of CPR expanded to

include patients with terminal illnesses and severe chronic conditions, raising important ethical

considerations regarding its use.

The historical expansion of CPR applications necessitated the development of DNR

orders to address the complexities surrounding end-of-life care. This evolution reflects an

increasing awareness of the importance of patient autonomy and the ethical need to respect

patients' wishes regarding life-prolonging treatments. As Ranasinghe highlights, the development

and refinement of CPR techniques also led to innovations such as interposed abdominal

compression CPR, which provided additional options within resuscitation practices (Ranasinghe,

2022). Moreover, the implementation of DNR orders has been influenced by broader ethical

debates and considerations, which are crucial in guiding end-of-life care practices. Discussions

about the appropriateness of CPR in various situations led to a nuanced understanding of its

implications for patient care. For instance, Kulkarni et al. discuss the heightened risks to

healthcare workers during the COVID-19 pandemic, adding a layer of ethical complexity to the

administration of CPR and the application of DNR orders (Kulkarni et al., 2020).

In addition, Naser's review of the seventy-five years of cardiac defibrillation illustrates

the critical advances in CPR technology and practice, which have directly impacted the ethical

frameworks surrounding DNR orders. The advent of portable defibrillators, for instance,
extended the reach of CPR from hospitals to public spaces, thus broadening the ethical landscape

and the need for clear DNR policies (Naser, 2023). Thus, the origin of DNR orders is not merely

a medical or historical note but a pivotal aspect of the ongoing ethical discourse in medical

practice, reflecting changing societal values and advances in medical technology.

Cardiopulmonary resuscitation (CPR) and Do Not Resuscitate (DNR) orders are critical

components in the management of patients with serious illnesses, especially within the context of

palliative care where the focus shifts from curative treatment to comfort and quality of life. CPR,

originally developed to revive individuals experiencing sudden cardiac arrest, has become a

common life-saving measure. However, its applicability becomes complex when considering

patients with advanced illnesses or at the end of life, leading to the adoption of DNR orders.

DNR orders, which instruct medical personnel not to perform CPR, address the ethical

need to respect patient autonomy and prevent unnecessary suffering. Redaction (2011) discusses

these issues in the context of palliative care, emphasizing that while medical advancements have

improved survival, they also create ethical dilemmas about prolonging life versus quality of life

(Redaction, 2011). The effectiveness of CPR, which can significantly influence decisions

regarding DNR orders, varies widely depending on numerous factors, including the patient's

overall health and the circumstances surrounding the cardiac arrest. For instance, Bai et al.

(2023) report that survival rates following CPR are notably lower in prehospital settings,

especially among patients with non-cardiac issues or delayed CPR initiation (Bai et al., 2023).

This has profound implications for how CPR is perceived in terms of realistic outcomes and

ethical implications in end-of-life care settings.

The ethical landscape of DNR orders has become even more complex during crises like

the COVID-19 pandemic, where the principles of maximum benefit and minimum risk must be
balanced against the harsh realities of overwhelmed healthcare systems. Gramma et al. (2021)

highlight the ethical challenges during the pandemic, noting that DNR decisions often had to be

made swiftly, which could overlook the patient's autonomy and dignity (Gramma, Bacoanu, &

Ioan, 2021). Furthermore, discussions around CPR and DNR in palliative care settings stress the

importance of aligning medical interventions with the patient's values and end-of-life wishes.

Nowarska (2012) addresses the application of CPR and the arrangement of DNR orders for

palliative care patients, underscoring the necessity of patient-centered care (Nowarska, 2012).

Therefore, the integration of CPR and DNR orders in patient care requires a thoughtful approach

that respects ethical principles, patient autonomy, and the complexities of individual health

conditions. Ensuring that these decisions align with the patient's wishes and clinical indications

is paramount for ethical medical practice.

As the use of CPR became more common, it sparked significant ethical debates,

particularly regarding its use in patients with poor prognoses, where it might prolong life without

improving the chances of a meaningful recovery. These discussions emphasized the need to

balance the technological capabilities of medical interventions with the ethical principles guiding

patient care. DNR orders emerged as a solution to these dilemmas, serving as a tool to respect

patient autonomy and prevent potential suffering caused by the unwanted extension of life

through medical interventions (American Heart Association, 2021).

The four ethical principles that we have discussed in class are critical in untangling the

dilemmas that come along with DNR orders. The first ethical principle that will be used to

analyze the issues surrounding DNR orders is principlism. Principlism is an approach in

bioethics that equally distributes perspectives to four main categories: Autonomy, beneficence,

non-maleficence, and justice. When two or more of these categories conflict, it makes for a
debate that could help settle the medical dilemma at hand. The first category, autonomy, is the

most prominent when it comes to DNR orders because they were first made to grant people more

rights over their bodies and quality of life. The practical application of autonomy in the context

of DNR orders involves ensuring that patients are given comprehensive information and

sufficient opportunity to reflect on their choices about CPR and other life-sustaining treatments.

This may include discussions about the likely outcomes of CPR, the patient’s prognosis, and the

quality-of-life considerations. Such discussions must be sensitive, respect the patient’s cultural

and personal values, and should ideally occur well before a crisis arises, allowing patients to

make these crucial decisions without pressure.

Beneficence involves acting in the best interest of the patient. Non-maleficence is the act

of doing no harm to the patient. These two categories are intertwined when it comes to DNR

orders because they are both being used to do what is in the patient’s best interest physically and

mentally. In the context of DNR orders, this often translates to assessing whether the application

of CPR would truly benefit the patient or merely prolong suffering. As Berger and colleagues

(2017) discuss, the transition from lifesaving to life-sustaining treatment can create scenarios

where the potential harm of intervention outweighs the benefits, making the ethical landscape

particularly complex.

Justice involves ensuring equal distribution of resources and impartiality in all medical

decisions among all patients. When considering DNR orders, issues of justice can arise if there

are perceptions of inequitable treatment based on age, disability, or other non-medical factors.

Furthermore, Pope (2017) highlights the legal implications and new penalties for disregarding

advance directives and DNR orders, emphasizing the importance of adhering to patient wishes as

a matter of justice and legal compliance.

at the arguments written out it is clear that autonomy has a very strong case as the whole

background and history of DNR order is based solely around an individual’s right to make

medical decisions involving their current health and future quality of life. However, one could

also argue that the act of not trying to save someone when they could be performing a potentially

lifesaving saving operation, which could be seen as a strong argument for non-maleficence. In

this case, I do believe that autonomy does trump non-maleficence because of the possibility of

that person having low to no quality of life. It is important for the patient to know that the

healthcare system does have their best interest at heart, which can only happen if healthcare

providers respect their informed decision.

The second ethical principle that will be used to analyze the issues surrounding DNR

orders is deontology. A deontologist viewpoint is rooted in duty-based principles and provides a

compelling framework for evaluating the ethicality of DNR orders by looking at the morality of

an action based not on its outcomes but how the decision-making process aligns with moral

norms and duties. This approach emphasizes the inherent rightness or wrongness of actions. The

first valuable aspect of deontology is respecting the autonomy of an individual. By doing this,

healthcare providers are respecting the individual’s intrinsic moral worth. In the case of DNR

orders, it is important for these providers to respect a person’s decisions, even if they are

declining life-sustaining interventions like CPR. The second aspect that is prevalent in this

discussion is the duty to tell the truth and maintain trust between the individual and healthcare

provider. It is the responsibility of the patient’s medical team to provide them with enough

information for them to make an informed decision about their end-of-life care, including

information about their medical condition and the repercussions of every outcome, the expected
outcomes of CPR, and the implications that come with DNR orders. This transparent

communication between the patient and the medical provider is crucial from a deontological

perspective. The third aspect of this discussion is the duty to uphold dignity and prevent harm.

What is harm in this situation: letting the person die without trying to save them, or ignoring the

patient’s wishes and providing them with care? This argument could vary based on a person’s

specific situation; for example, if the individual’s prognosis indicates that CPR would not only

be futile but also could exasperate suffering or compromise the patient’s remaining quality of

life, a DNR order may be seen as aligning with the deontological duty to avoid actions that

would cause unnecessary harm or indignity. From a deontological standpoint, it is not the

consequences of withholding CPR that justify a DNR, but rather the inherent duty to respect the

patient’s dignity and prevent harm.

The third ethical principle that will be used to analyze DNR orders is consequentialism.

Consequentialism involves evaluating the morality of these orders based on the outcomes they

produce. When looking from the viewpoint of a consequentialist, the primary consideration for

DNR orders is whether they serve to maximize well-being or minimize suffering. In cases where

CPR would likely lead to a poor quality of life, prolonged suffering, or a mere extension of the

dying process without a meaningful chance of recovery, a DNR order could be seen as

beneficial. If CPR is unlikely to restore a patient to a health state that they would consider

worthwhile, then not performing CPR could be seen as a way to prevent additional suffering,

thus maximizing overall well-being. Consequentialists would also look at how the people who

surround the patient, such as family, friends, healthcare providers, would be affected by the

manner of their death. The decision to implement DNR orders could potential save the family

and friends of the patient from having to see their loved one go in such an invasive and
potentially futile medical procedures. It also could potentially help them come to terms with an

impending loss, allowing them the time to focus on palliative care and quality time with the

patient rather than spending that time searching for ways to save them that have little chance of

success. Overall, a consequentialist would see these orders as being ethically justifiable if they

are being used to maximize overall well-being, minimize unnecessary suffering, and reduce

distress for those surrounding the patient.

The fourth ethical principle that will be used to analyze DNR orders is casuistry. This

involves comparing the current ethical dilemma with past cases and ethical principles to find a

resolution. Two cases that were discussed during the lecture will be used to draw conclusions in

the current discussion. The cases of Karen Quinlan and Nancy Cruzan are two similar situations

where the use of DNR orders were put into question. They delve into the topics of autonomy,

medical intervention, and end-of-life decisions which can help determine if these orders can be

justified.

The Karen Quinlan case consisted of a debate over the right to die when, after consuming

alcohol and drugs at party, she lapsed into a persistent vegetative state. Her parents sought legal

permission to disconnect her from the ventilator, arguing that she would not have wanted to live

in such a condition. The hospital was hesitant to take her off the ventilator without a court order,

which is how this case gained such importance. The court decision allowed her parents to make

the surrogate decision and take her off the ventilator, which highlights the importance of

respecting patient autonomy indirectly though family decision-making. This case supports the

argument for the justification of DNR orders on the grounds that the patient’s presumed wishes is

to not undergo life-sustaining treatments, such as CPR, in a vegetative state or in other similarly

low quality of life instances.

Her family’s request to terminate life-sustaining treatments including artificial nutrition and

hydration which led to a legal battle that reached the U.S. Supreme Court. The family waited for

years to see if her state would ever improve, but it never did. This case was so controversial

because originally the court ruled that Nancy’s parents should have the right to make the

surrogate decision for their daughter, but the state appealed the decision, emphasizing the state’s

interest in preserving life and the need for clear evidence that Nancy would have wanted to

withdraw treatment. This case highlights the tension between state interests in preserving life and

the individual’s right to refuse medical treatment and supports the use of DNR orders when there

is clear evidence, such as an advanced directive, of an individual’s wishes regarding end-of-life

care.

Both the Karen Quinlan and Nancy Cruzan cases provide crucial analogies for

understanding the ethical underpinnings of DNR orders from a casuist perspective. They

highlight the importance of respecting patient autonomy, even when the patient cannot directly

communicate their wishes. These cases also stress the role of surrogate decision-makers and

advance directives in ensuring that end-of-life care respects the values and desires of the patient,

supporting the implementation of DNR orders under appropriate circumstances.

The ethical landscape surrounding Do Not Resuscitate (DNR) orders is deeply nuanced

and intricately woven with of medical history, advancements in care, and shifting societal values.

The cases of Karen Quinlan and Nancy Cruzan, pivotal in shaping the discourse on patient

autonomy and the moral dimensions of end-of-life care, underscore the gravity and complexity

of such decisions. These cases do not merely serve as historical footnotes but as foundational

elements that continue to inform and guide ethical considerations and medical practices today.
DNR orders, as a manifestation of the evolving understanding of patient rights and medical

ethics, highlight the delicate balance between medical intervention and respect for the patient's

wishes. They embody the ethical principles of autonomy, beneficence, non-maleficence, and

justice, each playing a critical role in determining the appropriateness of medical interventions.

Through the lens of casuistry, the analogies drawn from Quinlan and Cruzan provide compelling

guidance for current and future cases, emphasizing the importance of context, patient-specific

details, and the precedence of established ethical practices.

Moreover, the integration of DNR orders into patient care exemplifies a commitment to

ethical medical practice, ensuring that decisions align with both the patients' wishes and clinical

indications. As medical technology advances and societal values evolve, the dialogue

surrounding DNR orders and end-of-life care will undoubtedly continue to evolve. However, the

principles gleaned from seminal cases and the ongoing ethical discourse provide a robust

framework for navigating these challenging waters. Therefore, the essence of DNR orders and

their ethical justification rest not only in historical precedence but also in a forward-looking,

principled approach to patient care. It reaffirms the medical community's duty to honor patient

autonomy, alleviate suffering, and pursue justice in healthcare delivery, ensuring that each

decision is made with compassion, respect, and ethical rigor. As we move forward, let us carry

the lessons learned from past cases into future applications, continually striving to enhance the

alignment of medical interventions with the deeply personal values and wishes of those we serve.
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