Origin, Maintenance and Future of Do-Not-Resuscitate (DNR)

Do not resuscitate orders and its impact on patient care is best understood knowing the perceptual historical origin of these orders? Simplistically, this process originated when the rapidly improving and innovating human interventions started ensuring the possibility of acute resuscitations in dying or almost dead patients. After the initial promising results of acute resuscitations settled down and sunk in the human society's psyche, it was time to oversee the potential for long term survivals after resuscitations. It will be appropriate to say that human society moved on to catering from heart-and-lungs as focal points of acute resuscitation to survivors’ brains as focal point of long term survival. Once the focus was directed to brain's survival, the human society realized that long term survival outcomes may be as important (or more important) to make-or-break the case for universal resuscitation expectations. With this realization, the society understood that acute cardiopulmonary resuscitation may only be buying the time to make appropriate subsequent decisions depending on whether the resuscitated brain will survive and if yes, how this surviving brain will behave. When it was time to make decisions, the owners of these resuscitated brains were found to be in no capacity of providing their input (or as they say “put their two cents”) worthy of making any justifiable decisions. Therefore, the brunt of this catch-22 situation fell upon the shoulders of treating health care providers (who were knowledgeable about historical or predictable outcomes of resuscitation interventions) and/or loving family surrogates (who were potentially aware of the patients’ perceptions about healthy lives). However, either of these decision-maker groups was supposed to be biased from their personal interpretations of clinical, familial, social and economic outlooks. Thereafter, the human society judged that it will be better to just direct the focus of these decision-making capacities back to the actual sufferers: The patients. Herein came the provisions of advance directives, living wills and DNR orders elicited from patients as documented (medical and/or legal) evidence of their personal wishes and therein absolving everyone else from potentially biased decisions about patients’ critical life-altering clinical scenarios.

So, what is the fuss about DNR? First of all, it (along with its brethren advance directives and living will) recognizes that advancements in medical technology have a ceiling effect until the times when human brain has been completely explored and understood anatomically, physiologically and aesthetically. Secondly, it is easier to fly away with the knowing that “I decided to board the ship” rather than living with the guilt that “I bought his/her ticket to that voyage”. Autonomy is part of the game that “who-else but me” will come forward to make responsible and informed decisions that have life-altering implications. Thirdly, it is worth acknowledging who is paying for all this. As someone once said that “Someone has to pay”, it is a matter of fact that irrespective of whether patients, their families and their insurance providers directly pay, or society and taxpayers indirectly cover for the healthcare payments induced debts, medical care costs to society and hence DNR with its brethren always have explicit, as well as implicit economic undertones. Finally, autonomy that was not naturally imparted to human beings at the time of their conceptions/births is finally achieved when they decide their futures around the process of their dying and subsequent imminent deaths.

Therefore, what next now? Few things are certain. Modern and rapidly evolving human societies (with constantly improvising medical technologies) cannot sustain or survive without clear cut and transparent DNR and related policies. Existence and implementations of these policies are more relevant than understanding about underlying reasons behind these policies because the underlying reasons may not be unbiased (even if the bias is only implicit and not explicit) which can interfere in societies’ collective conscience to deliver appropriate medical care. Quality of life supersedes quantity of life because life-years added secondary to modern innovations may be apparently inferior to life-years added secondary to natural resilience of tough human bodies wherein quality and quantity of life match step-by-step. Even though globalization of thought processes has taken place, it does not replace the local laws that govern the medical care. Therefore, it is important that health care providers practice according to the local laws; however, if changes are required based on cross-cultural and inter-continental awareness about the positive impact of DNR and related policies in other local societies and/or nations, the local communities of health care providers should motivate/instigate legislative and judiciary branches of their local societies and/or nations for reviewing and re-writing their local DNR and related policies.

In summary, DNR and related policies are fervor of modern health care with their growing needs, recognition and acceptance irrespective of underlying reasons for this growth.