Canadian Journal of Anaesthesia

, Volume 38, Issue 5, pp 553–563 | Cite as

Evaluation of a “do not resuscitate” policy in intensive care

  • George C. Webster
  • C. David Mazer
  • Carol A. Potvin
  • Anita Fisher
  • Robert J. Byrick
Reports of Investigation


The decision to withhold cardiopulmonary resuscitation from a patient within an intensive care unit (ICU) may be a difficult but appropriate one for which there are few guidelines. We describe the formulation of a Do Not Resuscitate (DNR) policy in our multidisciplinary ICU. To evaluate the effect of implementation of the DNR policy on physician practice and on communication among physicians, nurses, patients and their families, we interviewed physicians and nurses caring for patients designated DNR before (n = 8) and after (n = 17) implementation of the DNR policy. We found that DNR orders in the ICU were not infrequent (2–3 per week). All patients designated DNR were either irreversibly ill or not responsive to maximal therapy, and 22 of 25 were not competent. The DNR order was not accompanied by withdrawal of other therapy in 50% of cases and one patient recovered and was discharged from hospital. The implementation of the DNR policy encouraged greater physician consultation with other physicians, patients and their families. Although there were differences in perception of communication between physicians and nurses, we believe that the DNR policy influenced physician practice and enhanced overall communication in the ICU.

Key words

ethics: resuscitation intensive care 


La décision de s’abstenir à faire une réanimation cardiopulmonaire d’un patient aux soins intensifs (ICU) peut être difficile mais appropriée pour laquelle des rares directives sont actuellement disponibles. On déerit la formulation d’une politique de non-réanimation (DNR) dans notre unité multidisciplinaire de soins intensifs. Afin d’évaluer les effets de l’instauration de cette politique DNR sur la pratique médicate et sur la communication entre les médecins, les infirmières, les patients et leur famille, on a interviewé des médecins et des infirmières soignant ces patients avant (n = 8) et après (n = 17) application de cette politique. On a note que les ordres de DNR dans les soins intensifs n’étaient pas rares (2 à 3 par semaine). Tous les patients de ce groupe étaient soit malades d’une façon irréversible soit ne répondant pas à la thérapie maximale et 22 sur 25 étaient incompétents. L’ordre de DNR n’était pas accompagné d’un retrait des autres thérapies dans 50% des cas et un patient a récupéré et fut congédié de l’hôpital. La mise en place cette politique de DNR a encouragé une plus grande consultation entre les médecins, les patients et leur famille. Même s’il y avail une différence de perception dans la communication entre les médecins et les infirmiéres, on croit que cette politique a influencé la pratique médicale et a amélioré en général la communication aux soins intensifs.


  1. 1.
    Smedira NG, Evans BH, Grais LS et al. Withholding and withdrawal of life support from the critically ill. N Engl J Med 1990; 322: 309–15.PubMedGoogle Scholar
  2. 2.
    Joint Statement on Terminal Illness: a protocol for health professionals regarding rcsuscitative intervention for the terminally ill. Canadian Nurses Association, Canadian Medical Association, Canadian Hospital Association, 1986.Google Scholar
  3. 3.
    Bone RC, Rackow EC, Weg JC. Members of ACCP/ SCCM Consensus Panel Ethical and Moral Guidelines for the Initiation, Continuation and Withdrawl of Intensive Care. Chest 1990; 97: 949–58.CrossRefGoogle Scholar
  4. 4.
    Bedell SE, Pelle D, et al. Do not resuscitation orders for critically ill patients in the hospital. How arc they used and what is their impact? JAMA 1986; 256: 233–7.PubMedCrossRefGoogle Scholar
  5. 5.
    Youngner SJ. Do not resuscitate orders: no longer secret, but still a problem. Hastings Centre Report, Feb. 1987; 30–1.Google Scholar
  6. 6.
    Zimmerman JE, Knaus WA, Sharpe SM, Anderson AS, Draper ES, Wagner DP. The use and implications of Do Not Resuscitate order in Intensive Care Units. JAMA 1986; 255: 351–6.PubMedCrossRefGoogle Scholar
  7. 7.
    Gremelspacher GP, Horvell JD. Perceptions of ethical problems by nurses and doctors. Arch Intern Med 1986; 146: 577–8.CrossRefGoogle Scholar
  8. 8.
    Charleson ME, Sax FL, MacKenzie R, Fields SD, Braham RL, Douglas G. Resuscitation — how do we decide: a prospective study of physicians’ preferences and the clinical course of hospitalized patients. JAMA 1986; 255: 1316–22.CrossRefGoogle Scholar
  9. 9.
    Ginzberg E. What physicians should know about the nursing shortage. Ann Int Med 1990; 112: 319–20.PubMedGoogle Scholar
  10. 10.
    Youngner SJ. Who defines futility? JAMA 1988; 260: 2094–5.PubMedCrossRefGoogle Scholar
  11. 11.
    Lantos JD, Singer PA, Walker RM et al. The illusion of futility in clinical practice. Am J Med 1989; 87: 81–4.PubMedCrossRefGoogle Scholar
  12. 12.
    President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to forego life-sustaining treatment: ethical medical and legal issues in treatment decisions. Washington,. D.C., U.S. Government Printing Office, 1983; 251.Google Scholar

Copyright information

© Canadian Anesthesiologists 1991

Authors and Affiliations

  • George C. Webster
    • 1
  • C. David Mazer
    • 1
  • Carol A. Potvin
    • 2
  • Anita Fisher
    • 2
  • Robert J. Byrick
    • 1
  1. 1.Department of AnaesthesiaSt. Michael’s Hospital, University of TorontoCanada
  2. 2.Department of NursingSt. Michael’s Hospital, University of TorontoCanada

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