Editing Do not resuscitate (section)

==Basis for choice==

[[Interview|Interviews]] with 26 DNR patients and 16 full code patients in [[Toronto]], Canada in 2006–2009 suggest that the decision to choose do-not-resuscitate status was based on personal factors including [[health]] and lifestyle; relational factors (to family or to society as a whole); and philosophical factors.<ref name="choice">{{cite journal | vauthors = Downar J, Luk T, Sibbald RW, Santini T, Mikhael J, Berman H, Hawryluck L | title = Why do patients agree to a "Do not resuscitate" or "Full code" order? Perspectives of medical inpatients | journal = Journal of General Internal Medicine | volume = 26 | issue = 6 | pages = 582–7 | date = June 2011 | pmid = 21222172 | pmc = 3101966 | doi = 10.1007/s11606-010-1616-2 }}</ref> Audio recordings of 19 discussions about DNR status between doctors and patients in two US hospitals (San Francisco, California and Durham, North Carolina) in 2008–2009 found that patients "mentioned risks, benefits, and outcomes of CPR," and doctors "explored preferences for short- versus long-term use of life-sustaining therapy."<ref name="anderson">{{cite journal | vauthors = Anderson WG, Chase R, Pantilat SZ, Tulsky JA, Auerbach AD | title = Code status discussions between attending hospitalist physicians and medical patients at hospital admission | journal = Journal of General Internal Medicine | volume = 26 | issue = 4 | pages = 359–66 | date = April 2011 | pmid = 21104036 | pmc = 3055965 | doi = 10.1007/s11606-010-1568-6 }}</ref> A Canadian article suggests that it is inappropriate to offer CPR when the clinician knows the patient has a terminal illness and that CPR will be futile.<ref>{{Cite journal |last1=Ginn |first1=D. |last2=Zitner |first2=D. |date=1995 |title=Cardiopulmonary resuscitation. Not for all terminally ill patients. |journal=Canadian Family Physician |volume=41 |pages=649–657 |issn=0008-350X |pmc=2146529 |pmid=7787495}}</ref>

===Outcomes of CPR===
{{Main|Cardiopulmonary resuscitation#Survival differences, based on prior illness, age or location}}
[[File:CPR-groups.png|thumb|370px|Survival from CPR among various groups]]

When medical institutions explain DNR, they describe survival from CPR, in order to address patients' concerns about outcomes. After CPR in hospitals in 2017, 7,000 patients survived to leave the hospital alive, out of 26,000 CPR attempts, or 26%.<ref name="aha2019">{{cite journal | vauthors = Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, Delling FN, Djousse L, Elkind MS, Ferguson JF, Fornage M, Jordan LC, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, O'Flaherty M, Pandey A, Perak AM, Rosamond WD, Roth GA, Sampson UK, Satou GM, Schroeder EB, Shah SH, Spartano NL, Stokes A, Tirschwell DL, Tsao CW, Turakhia MP, VanWagner LB, Wilkins JT, Wong SS, Virani SS | display-authors = 6 | title = Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association | journal = Circulation | volume = 139 | issue = 10 | pages = e56–e528 | date = March 2019 | pmid = 30700139 | doi = 10.1161/cir.0000000000000659 | doi-access = free }}</ref> After CPR outside hospitals in 2018, 8,000 patients survived to leave the hospital alive, out of 80,000 CPR attempts, or 10%. Success was 21% in a public setting, where someone was more likely to see the person collapse and give help than in a home.<ref name="mycares"/> Success was 35% when bystanders used an [[Automated external defibrillator]] (AED), outside health facilities and nursing homes.<ref name="mycares"/>

In information on DNR, medical institutions compare survival for patients with multiple chronic illnesses;<ref name="coal">{{Cite web |url=https://www.uclahealth.org/palliative-care/Workfiles/CPR-Decision-Making-Guide.pdf |title=CPR/DNR |last=COALITION for COMPASSIONATE CARE of CALIFORNIA |date=2010 |website=UCLA |access-date=2019-05-03 |archive-date=2019-05-03 |archive-url=https://web.archive.org/web/20190503172139/https://www.uclahealth.org/palliative-care/Workfiles/CPR-Decision-Making-Guide.pdf |url-status=dead }}</ref><ref name="wv">{{Cite web |url=http://wvendoflife.org/media/1050/dnr-brochure.pdf |title=DNR Card (Do Not Resuscitate) |author1=WV Center for End of Life Care |author2=WV Department of Health and Human Services |date=2016 |access-date=2019-05-03 |archive-date=2019-02-14 |archive-url=https://web.archive.org/web/20190214214805/http://wvendoflife.org/media/1050/dnr-brochure.pdf |url-status=dead }}</ref> patients with heart, lung or kidney disease;<ref name="coal"/><ref name="wv"/> liver disease;<ref name="coal"/> widespread cancer<ref name="coal"/><ref name="wv"/><ref name="brigham">{{Cite web |url=https://www.brighamandwomensfaulkner.org/patients-and-families/advance-care-directives/dnr-orders |title=Understanding Do Not Resuscitate (DNR) Orders - Brigham and Women's Faulkner Hospital |website=www.brighamandwomensfaulkner.org |access-date=2019-05-03}}</ref> or infection;<ref name="brigham"/> and residents of nursing homes.<ref name="coal"/> Research shows that CPR survival is the same as the average CPR survival rate, or nearly so, for patients with multiple chronic illnesses,<ref name="ehlenbach">{{cite journal | vauthors = Ehlenbach WJ, Barnato AE, Curtis JR, Kreuter W, Koepsell TD, Deyo RA, Stapleton RD | title = Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly | journal = The New England Journal of Medicine | volume = 361 | issue = 1 | pages = 22–31 | date = July 2009 | pmid = 19571280 | pmc = 2917337 | doi = 10.1056/NEJMoa0810245 }}</ref><ref name="carew">{{cite journal | vauthors = Carew HT, Zhang W, Rea TD | title = Chronic health conditions and survival after out-of-hospital ventricular fibrillation cardiac arrest | journal = Heart | volume = 93 | issue = 6 | pages = 728–31 | date = June 2007 | pmid = 17309904 | pmc = 1955210 | doi = 10.1136/hrt.2006.103895 }}</ref> or diabetes, heart or lung diseases.<ref name="merchant">{{cite journal | vauthors = Merchant RM, Berg RA, Yang L, Becker LB, Groeneveld PW, Chan PS | title = Hospital variation in survival after in-hospital cardiac arrest | journal = Journal of the American Heart Association | volume = 3 | issue = 1 | pages = e000400 | date = January 2014 | pmid = 24487717 | pmc = 3959682 | doi = 10.1161/JAHA.113.000400 }}</ref> Survival is about half as good as the average rate, for patients with kidney or liver disease,<ref name="merchant"/> or widespread cancer<ref name="merchant"/><ref name="bruckel">{{cite journal | vauthors = Bruckel JT, Wong SL, Chan PS, Bradley SM, Nallamothu BK | title = Patterns of Resuscitation Care and Survival After In-Hospital Cardiac Arrest in Patients With Advanced Cancer | journal = Journal of Oncology Practice | volume = 13 | issue = 10 | pages = e821–e830 | date = October 2017 | pmid = 28763260 | pmc = 5640412 | doi = 10.1200/JOP.2016.020404 }}</ref> or infection.<ref name="merchant"/>

For people who live in nursing homes, survival after CPR is about half to three quarters of the average rate.<ref name="mycares"/><ref name="ehlenbach"/><ref name="merchant"/><ref name="abbo">{{cite journal | vauthors = Abbo ED, Yuen TC, Buhrmester L, Geocadin R, Volandes AE, Siddique J, Edelson DP | title = Cardiopulmonary resuscitation outcomes in hospitalized community-dwelling individuals and nursing home residents based on activities of daily living | journal = Journal of the American Geriatrics Society | volume = 61 | issue = 1 | pages = 34–9 | date = January 2013 | pmid = 23311551 | doi = 10.1111/jgs.12068 | s2cid = 36483449 }}</ref><ref name="soholm">{{cite journal | vauthors = Søholm H, Bro-Jeppesen J, Lippert FK, Køber L, Wanscher M, Kjaergaard J, Hassager C | title = Resuscitation of patients suffering from sudden cardiac arrests in nursing homes is not futile | journal = Resuscitation | volume = 85 | issue = 3 | pages = 369–75 | date = March 2014 | pmid = 24269866 | doi = 10.1016/j.resuscitation.2013.10.033 }}</ref> In health facilities and nursing homes where [[Automated external defibrillator|AEDs]] are available and used, survival rates are twice as high as the average survival found in nursing homes overall.<ref name="mycares"/> Few nursing homes have AEDs.<ref name="ullman">{{Cite journal |last1=Ullman |first1=Edward A. |last2=Sylvia |first2=Brett |last3=McGhee |first3=Jonathan |last4=Anzalone |first4=Brendan |last5=Fisher |first5=Jonathan |date=2007-07-01 |title=Lack of Early Defibrillation Capability and Automated External Defibrillators in Nursing Homes |url=https://www.jamda.com/article/S1525-8610(07)00207-1/abstract |journal=Journal of the American Medical Directors Association |language=en |location=Berlin/Heidelberg |publisher=Springer-Verlag |volume=8 |issue=6 |pages=413–415 |doi=10.1016/j.jamda.2007.04.001 |issn=1525-8610 |pmid=17619041}}</ref>

Research on 26,000 patients found similarities in the health situations of patients with and without DNRs. For each of 10 levels of illness, from healthiest to sickest, 7% to 36% of patients had DNR orders; the rest had full code.<ref name="fendler">{{cite journal | vauthors = Fendler TJ, Spertus JA, Kennedy KF, Chen LM, Perman SM, Chan PS | title = Alignment of Do-Not-Resuscitate Status With Patients' Likelihood of Favorable Neurological Survival After In-Hospital Cardiac Arrest | journal = JAMA | volume = 314 | issue = 12 | pages = 1264–71 | date = 2015-09-22 | pmid = 26393849 | pmc = 4701196 | doi = 10.1001/jama.2015.11069 }}</ref>

===Risks===
{{Main|Cardiopulmonary resuscitation#Consequences}}

As noted above, patients considering DNR mention the risks of CPR. Physical injuries, such as broken bones, affect 13% of CPR patients,<ref name="boland">{{cite journal | vauthors = Boland LL, Satterlee PA, Hokanson JS, Strauss CE, Yost D | title = Chest Compression Injuries Detected via Routine Post-arrest Care in Patients Who Survive to Admission after Out-of-hospital Cardiac Arrest | journal = Prehospital Emergency Care | volume = 19 | issue = 1 | pages = 23–30 | date = January–March 2015 | pmid = 25076024 | doi = 10.3109/10903127.2014.936636 | s2cid = 9438700 }}</ref> and an unknown additional number have broken cartilage which can sound like breaking bones.<ref name="creighton">{{Cite web |url=http://heartsavercpromaha.com/cpr-review---keeping-it-real.html |title=CPR Review - Keeping It Real |website=HEARTSAVER (BLS Training Site) CPR/AED & First Aid (Bellevue, NE) |access-date=2018-12-12 |archive-date=2018-12-15 |archive-url=https://web.archive.org/web/20181215222028/http://heartsavercpromaha.com/cpr-review---keeping-it-real.html |url-status=dead }}</ref><ref name="emt">{{Cite web |url=http://emtlife.com/threads/cpr-breaking-bones.23116/ |title=CPR Breaking Bones |website=EMTLIFE |date=25 May 2011 |access-date=2018-12-12}}</ref>

Mental problems affect some patients, both before and after CPR. After CPR, up to 1 more person, among each 100 survivors, is in a coma than before CPR (and most people come out of comas<ref name="katz">{{Cite journal |last1=Katz |first1=Douglas I. |last2=Polyak |first2=Meg |last3=Coughlan |first3=Daniel |last4=Nichols |first4=Meliné |last5=Roche |first5=Alexis |date=2009-01-01 |editor-last=Laureys |editor-first=Steven |editor2-last=Schiff |editor2-first=Nicholas D. |editor3-last=Owen |editor3-first=Adrian M. |title=Natural history of recovery from brain injury after prolonged disorders of consciousness: outcome of patients admitted to inpatient rehabilitation with 1–4 year follow-up |series=Coma Science: Clinical and Ethical Implications |publisher=Elsevier |volume=177 |pages=73–88}}</ref><ref name="neurol">{{Cite journal |last1=Giacino |first1=Joseph T. |last2=Katz |first2=Douglas I. |last3=Schiff |first3=Nicholas D. |last4=Whyte |first4=John |last5=Ashman |first5=Eric J. |last6=Ashwal |first6=Stephen |last7=Barbano |first7=Richard |last8=Hammond |first8=Flora M. |last9=Laureys |first9=Steven |date=2018-08-08 |title=Practice guideline update recommendations summary: Disorders of consciousness |journal=Neurology |volume=91 |issue=10 |pages=450–460 |doi=10.1212/WNL.0000000000005926 |pmid=30089618 |pmc=6139814 |issn=0028-3878}}</ref>). Five to 10 more people, of each 100 survivors, need more help with daily life than they did before CPR. Five to 21 more people, of each 100 survivors, decline mentally, but stay independent.<ref name="mental">The ranges given in the text above represent outcomes ''inside'' and ''outside'' of hospitals:
* ''In US hospitals'' a study of 12,500 survivors after CPR, 2000–2009, found: 1% more survivors of CPR were in comas than before CPR (3% before, 4% after), 5% more survivors were dependent on other people, and 5% more had moderate mental problems but were still independent. '''['''{{cite journal | vauthors = Chan PS, Spertus JA, Krumholz HM, Berg RA, Li Y, Sasson C, Nallamothu BK | title = Supplement of A validated prediction tool for initial survivors of in-hospital cardiac arrest | journal = Archives of Internal Medicine | volume = 172 | issue = 12 | pages = 947–53 | date = June 2012 | pmid = 22641228 | pmc = 3517176 | doi = 10.1001/archinternmed.2012.2050}}''']'''
* ''Outside hospitals'', half a percent more survivors were in comas after CPR (0.5% before, 1% after), 10% more survivors were dependent on other people because of mental problems, and 21% more had moderate mental problems which still let them stay independent. This study covered 419 survivors of CPR in Copenhagen in 2007-2011.  {{doi|10.1016/j.resuscitation.2013.10.033}} and works cited.</ref>

===Organ donation===

[[Organ donation]] is possible after CPR, but not usually after a death with a DNR. If CPR does not revive the patient, and continues until an operating room is available, then kidneys and liver can be considered for donation. US Guidelines endorse organ donation, "Patients who do not have ROSC (return of spontaneous circulation) after resuscitation efforts and who would otherwise have termination of efforts may be considered candidates for kidney or liver donation in settings where programs exist."<ref name="ecc-donate">{{Cite journal |date=2015 |title=Part 8: Post-Cardiac Arrest Care – ECC Guidelines, section 11 |url=https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-8-post-cardiac-arrest-care/?strue=1&id=11 |journal=Resuscitation Science, Section 11 }}</ref> European guidelines encourage donation, "After stopping CPR, the possibility of ongoing support of the circulation and transport to a dedicated centre in perspective of organ donation should be considered."<ref>{{Cite journal |last=Bossaert|display-authors=etal|date=2015 |title=European Resuscitation Council Guidelines for Resuscitation 2015: Section 11. The ethics of resuscitation and end-of-life decisions |url=https://ercguidelines.elsevierresource.com/european-resuscitation-council-guidelines-resuscitation-2015-section-11-ethics-resuscitation-and-end/fulltext |journal=Resuscitation |volume=95|pages=302–11|access-date=2019-01-24|doi=10.1016/j.resuscitation.2015.07.033|pmid=26477419|doi-access=free|hdl=10067/1303020151162165141|hdl-access=free}}</ref> CPR revives 64% of patients in hospitals<ref name="girotra-race">{{cite journal | vauthors = Joseph L, Chan PS, Bradley SM, Zhou Y, Graham G, Jones PG, Vaughan-Sarrazin M, Girotra S | title = Temporal Changes in the Racial Gap in Survival After In-Hospital Cardiac Arrest | journal = JAMA Cardiology | volume = 2 | issue = 9 | pages = 976–984 | date = September 2017 | pmid = 28793138 | pmc = 5710174 | doi = 10.1001/jamacardio.2017.2403 }}</ref> and 43% outside<ref name="mycares">{{Cite web |url=https://mycares.net/sitepages/reports.jsp |title=National Reports by Year | publisher = MyCares.net |access-date=2018-12-12}}</ref> (ROSC), which gives families a chance to say goodbye,<ref>{{cite journal | vauthors = Breu AC | title = Clinician-Patient Discussions of Successful CPR-The Vegetable Clause | journal = JAMA Internal Medicine | volume = 178 | issue = 10 | pages = 1299–1300 | date = October 2018 | pmid = 30128558 | doi = 10.1001/jamainternmed.2018.4066 | s2cid = 52047054 }}</ref> and all organs can be considered for donation, "We recommend that all patients who are resuscitated from cardiac arrest but who subsequently progress to death or brain death be evaluated for organ donation."<ref name="ecc-donate"/>

1,000 organs per year in the US are transplanted from patients who had CPR.<ref name="orioles">{{cite journal | vauthors = Orioles A, Morrison WE, Rossano JW, Shore PM, Hasz RD, Martiner AC, Berg RA, Nadkarni VM | title = An under-recognized benefit of cardiopulmonary resuscitation: organ transplantation | journal = Critical Care Medicine | volume = 41 | issue = 12 | pages = 2794–9 | date = December 2013 | pmid = 23949474 | doi = 10.1097/CCM.0b013e31829a7202 | s2cid = 30112782 }}</ref> Donations can be taken from 40% of patients who have ROSC and later become brain dead,<ref name="sandroni">{{cite journal | vauthors = Sandroni C, D'Arrigo S, Callaway CW, Cariou A, Dragancea I, Taccone FS, Antonelli M | title = The rate of brain death and organ donation in patients resuscitated from cardiac arrest: a systematic review and meta-analysis | journal = Intensive Care Medicine | volume = 42 | issue = 11 | pages = 1661–1671 | date = November 2016 | pmid = 27699457 | pmc = 5069310 | doi = 10.1007/s00134-016-4549-3 }}</ref> and an average of 3 organs are taken from each patient who donates organs.<ref name="orioles"/> DNR does not usually allow organ donation.

===Less care for DNR patients===

Reductions in other care are not supposed to result from a DNAPR decision being in place.<ref name="medline-dnr"/> Some patients choose DNR because they prefer less care: Half of Oregon patients with DNR orders who filled out a [[POLST]] (known as a Physician Orders and Scope of Treatment, or POST, in Tennessee) wanted only comfort care, and 7% wanted full care. The rest wanted various limits on care, so blanket assumptions are not reliable.<ref name="tolle-2015">{{Cite journal |last1=Tolle |first1=Susan W. |last2=Olszewski |first2=Elizabeth |last3=Schmidt |first3=Terri A. |last4=Zive |first4=Dana |last5=Fromme |first5=Erik K. |date=2012-01-04 |title=POLST Registry Do-Not-Resuscitate Orders and Other Patient Treatment Preferences |journal=JAMA |volume=307 |issue=1 |pages=34–35 |doi=10.1001/jama.2011.1956 |pmid=22215159 |issn=0098-7484|doi-access=free }}</ref> There are many doctors "misinterpreting DNR preferences and thus not providing other appropriate therapeutic interventions."<ref name="fendler"/>

Patients with DNR are less likely to get medically appropriate care for a wide range of issues such as blood transfusions, cardiac catheterizations, cardiac bypass, operations for surgical complication,<ref name="horwitz">{{cite journal | vauthors = Horwitz LI | title = Implications of Including Do-Not-Resuscitate Status in Hospital Mortality Measures | journal = JAMA Internal Medicine | volume = 176 | issue = 1 | pages = 105–6 | date = January 2016 | pmid = 26662729 | doi = 10.1001/jamainternmed.2015.6845 }}</ref> blood cultures, central line placement,<ref name="smith2008">{{cite journal | vauthors = Smith CB, Bunch O'Neill L | title = Do not resuscitate does not mean do not treat: how palliative care and other modalities can help facilitate communication about goals of care in advanced illness | journal = The Mount Sinai Journal of Medicine, New York | volume = 75 | issue = 5 | pages = 460–5 | date = October 2008 | pmid = 18828169 | doi = 10.1002/msj.20076 }}</ref> antibiotics and diagnostic tests.<ref name="yuen">{{cite journal | vauthors = Yuen JK, Reid MC, Fetters MD | title = Hospital do-not-resuscitate orders: why they have failed and how to fix them | journal = Journal of General Internal Medicine | volume = 26 | issue = 7 | pages = 791–7 | date = July 2011 | pmid = 21286839 | pmc = 3138592 | doi = 10.1007/s11606-011-1632-x }}</ref> "Providers intentionally apply DNR orders broadly because they either assume that patients with DNR orders would also prefer to abstain from other life-sustaining treatments or believe that other treatments would not be medically beneficial."<ref name="yuen"/> 60% of surgeons do not offer operations with over 1% mortality to patients with DNRs.<ref name="surgeons">{{cite journal | vauthors = Schwarze ML, Redmann AJ, Alexander GC, Brasel KJ | title = Surgeons expect patients to buy-in to postoperative life support preoperatively: results of a national survey | journal = Critical Care Medicine | volume = 41 | issue = 1 | pages = 1–8 | date = January 2013 | pmid = 23222269 | pmc = 3624612 | doi = 10.1097/CCM.0b013e31826a4650 }}</ref> The failure to offer appropriate care to patients with DNR led to the development of emergency care and treatment plans (ECTPs), such as the [[ReSPECT process|Recommended Summary Plan for Emergency Care and Treatment]] (ReSPECT), which aim to record recommendations concerning DNR alongside recommendations for other treatments in an emergency situation.<ref name="Hawkes 2020">{{cite journal |last1=Hawkes |first1=C |title=Development of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) |journal=Resuscitation |date=2020 |volume=148 |pages=98–107|doi=10.1016/j.resuscitation.2020.01.003 |pmid=31945422 |s2cid=210703171 |url=http://wrap.warwick.ac.uk/131965/1/WRAP-Development-Recommended-Summary-Plan-Emergency-Care-Treatment-%28ReSPECT%29-Hawkes-2020.pdf }}</ref> ECTPs have prompted doctors to contextualize CPR within a broader consideration of treatment options, however ECTPs are most frequently completed for patients at risk of sudden deterioration and the focus tends to be on DNR.<ref name="Eli 2020">{{cite journal |last1=Eli |first1=K |title=Secondary care consultant clinicians' experiences of conducting emergency care and treatment planning conversations in England: an interview-based analysis |journal=BMJ Open |date=2020 |volume=20 |issue=1 |pages=e031633|doi=10.1136/bmjopen-2019-031633 |pmid=31964663 |pmc=7044868 }}</ref>

Patients with DNR therefore die sooner, even from causes unrelated to CPR. A study grouped 26,300 very sick hospital patients in 2006–2010 from the sickest to the healthiest, using a detailed scale from 0 to 44. They compared survival for patients at the same level, with and without DNR orders. In the healthiest group, 69% of those without DNR survived to leave the hospital, while only 7% of equally healthy patients with DNR survived. In the next-healthiest group, 53% of those without DNR survived, and 6% of those with DNR. Among the sickest patients, 6% of those without DNR survived, and none with DNR.<ref name="fendler"/>

Two Dartmouth College doctors note that "In the 1990s&nbsp;... 'resuscitation' increasingly began to appear in the medical literature to describe strategies to treat people with reversible conditions, such as IV fluids for shock from bleeding or infection... the meaning of DNR became ever more confusing to health-care providers."<ref name="malhi">{{Cite news |url=https://thehill.com/opinion/healthcare/442188-the-term-do-not-resuscitate-should-be-laid-to-rest |title=The term 'do not resuscitate' should be laid to rest |last=Malhi |first=Sabrina | name-list-style = vanc |date=2019-05-05 |access-date=2019-05-29 }}</ref> Other researchers confirm this pattern, using "resuscitative efforts" to cover a range of care, from treatment of allergic reaction to surgery for a broken hip.<ref name="marco2018">{{cite journal | vauthors = Marco CA, Mozeleski E, Mann D, Holbrook MB, Serpico MR, Holyoke A, Ginting K, Ahmed A | title = Advance directives in emergency medicine: Patient perspectives and application to clinical scenarios | journal = The American Journal of Emergency Medicine | volume = 36 | issue = 3 | pages = 516–518 | date = March 2018 | pmid = 28784259 | doi = 10.1016/j.ajem.2017.08.002 }}</ref> Hospital doctors do not agree which treatments to withhold from DNR patients, and document decisions in the chart only half the time.<ref name="smith2008"/> A survey with several scenarios found doctors "agreed or strongly agreed to initiate fewer interventions when a DNR order was present.<ref name="smith2008" />

After successful CPR, hospitals often discuss putting the patient on DNR, to avoid another resuscitation. Guidelines generally call for a 72-hour wait to see what the prognosis is,<ref name="prognos">{{cite journal | journal = CPR & ECC Guidelines |url=https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-3-ethical-issues/?strue=1&id=7-1 | title = Resuscitation, Item 7.1, Prognostication  | publisher = The American Heart Association | quote = Part 3: Ethical Issues – ECC Guidelines, Timing of Prognostication in Post–Cardiac Arrest Adults }}</ref> but within 12 hours, US hospitals put up to 58% of survivors on DNR, and at the median hospital, 23% received DNR orders at this early stage, much earlier than the guideline. The hospitals putting fewest patients on DNR had more successful survival rates, which the researchers suggest shows their better care in general.<ref name="fendler"/> When CPR happened outside the hospital, hospitals put up to 80% of survivors on DNR within 24 hours, with an average of 32.5%. The patients who received DNR orders had less treatment, and almost all died in the hospital. The researchers say families need to expect death if they agree to DNR in the hospital.<ref name="richardson2013"/>

=== Controlled organ donation after circulatory death ===
In 2017, Critical Care Medicine (Ethics) and the American Society of Anesthesiologists (ASA) Committees on Transplant Anesthesia issued a statement regarding organ donation after circulatory death (DCD).<ref name="asahq.org">{{Cite web |title=Statement on Controlled Organ Donation After Circulatory Death |url=https://www.asahq.org/standards-and-guidelines/statement-on-controlled-organ-donation-after-circulatory-death |access-date=2022-09-12 |website=www.asahq.org}}</ref> The purpose of the statement is to provide an educational tool for institutions choosing to use DCD. In 2015, nearly 9% of organ transplantations in the United States resulted from DCD, indicating it is a widely-held practice. According to the President's Commission on Death Determination, there are two sets of criteria used to define circulatory death: irreversible absence of circulation and respiration, and irreversible absence of whole brain function. Only one criterion needs to be met for the determination of death before organ donation and both have legal standing, according to the 1980 Uniform Determination of Death Act (UDDA); a determination of death must be according to accepted medical standards.<ref>{{Cite web |title=Determination of Death Act - Uniform Law Commission |url=https://www.uniformlaws.org/committees/community-home?CommunityKey=155faf5d-03c2-4027-99ba-ee4c99019d6c#:~:text=Description&text=The%20Uniform%20Determination%20of%20Death,or%20the%20right%20to%20die. |access-date=2022-09-12 |website=www.uniformlaws.org |language=en}}</ref> All states within the United States adhere to the original or modified UDDA. The dead donor role states that a patient should not be killed for or by the donation of their organs and that organs can only be procured from dead people (lungs, kidneys, and lobes of a liver may be donated by living donors in certain highly regulated situations).

The definition of irreversibility centers around an obligatory period of observation to determine that respiration and circulation have ceased and will not resume spontaneously. Clinical examination alone may be sufficient to determine irreversibility, but the urgent time constraints of CDC may require more definitive proof of cessation with confirmatory tests, such as intra-arterial monitoring or Doppler studies. In accordance with the Institute of Medicine, the obligatory period for DCD is longer than 2 minutes but no more than 5 minutes of absent circulatory function before pronouncing the patient dead, which is supported by a lack of literature indicating that spontaneous resuscitation occurs after two minutes of arrest and that ischemic damage to perfusable organs occurs within 5 minutes.<ref>{{Cite book |last=Institute of Medicine (US) Committee on Non-Heart-Beating Transplantation II: The Scientific and Ethical Basis for Practice and Protocols |url=http://www.ncbi.nlm.nih.gov/books/NBK225025/ |title=Non-Heart-Beating Organ Transplantation: Practice and Protocols |date=2000 |publisher=National Academies Press (US) |isbn=978-0-309-06641-9 |location=Washington (DC) |pmid=25077239}}</ref>

Most patients considered for DCD will have been in the intensive care unit (ICU) and are dependent on ventilatory and circulatory support. Potential DCD donors are still completing the dying process but have not yet been declared dead, so quality end-of-life care should remain the absolute top priority and must not be compromised by the DCD process. The decision to allow death to occur by withdrawing life-sustaining therapies needs to have been made in accordance to the wishes of the patient and/or their legal agent; this must happen prior to any discussions about DCD, which should ideally occur between the patient's primary care giver and the patient's agent after rapport has been established.<ref name="asahq.org"/>

===Patient values===

The philosophical factors and preferences mentioned by patients and doctors are treated in the medical literature as strong guidelines for care, including DNR or CPR. "Complex medical aspects of a patient with a critical illness must be integrated with considerations of the patient's values and preferences"<ref name="burns2007">{{cite journal | vauthors = Burns JP, Truog RD | title = Futility: a concept in evolution | journal = Chest | volume = 132 | issue = 6 | pages = 1987–93 | date = December 2007 | pmid = 18079232 | doi = 10.1378/chest.07-1441 }}</ref> and "the preeminent place of patient values in determining the benefit or burden imposed by medical interventions."<ref name="armstrong2014">{{Cite journal |last=Armstrong |title=Medical Futility and Nonbeneficial Interventions |date=2014 |url=https://www.mayoclinicproceedings.org/article/S0025-6196(14)00793-9/fulltext: |journal=Mayo Clinic Proceedings |volume=89 |issue=12 |pages=1599–607 |doi=10.1016/j.mayocp.2014.08.017 |pmid=25441398 |doi-access=free }} {{Dead link|date=March 2022 |bot=InternetArchiveBot |fix-attempted=yes }}</ref> Patients' most common goals include talking, touch, prayer, helping others, addressing fears, and laughing.<ref name="steinhauser2000">{{Cite journal |last=Steinhauser |title=Factors Considered Important at the End of Life by Patients, Family, Physicians, and Other Care Providers |date=2000 |url=https://jamanetwork.com/journals/jama/articlepdf/193279/JOC00645.pdf |journal=JAMA|volume=284 |issue=19 |pages=2476–82 |doi=10.1001/jama.284.19.2476 |pmid=11074777 |doi-access=free }}</ref><ref name="reinke">{{cite journal | vauthors = Reinke LF, Uman J, Udris EM, Moss BR, Au DH | title = Preferences for death and dying among veterans with chronic obstructive pulmonary disease | journal = The American Journal of Hospice & Palliative Care | volume = 30 | issue = 8 | pages = 768–72 | date = December 2013 | pmid = 23298873 | doi = 10.1177/1049909112471579 | s2cid = 24353297 }}</ref> Being mentally aware was as important to patients as avoiding pain, and doctors underestimated its importance and overestimated the importance of pain.<ref name="steinhauser2000"/> Dying at home was less important to most patients.<ref name="steinhauser2000"/> Three quarters of patients prefer longer survival over better health.<ref name="brunner 2012">{{cite journal | vauthors = Brunner-La Rocca HP, Rickenbacher P, Muzzarelli S, Schindler R, Maeder MT, Jeker U, Kiowski W, Leventhal ME, Pfister O, Osswald S, Pfisterer ME, Rickli H | display-authors = 6 | title = End-of-life preferences of elderly patients with chronic heart failure | journal = European Heart Journal | volume = 33 | issue = 6 | pages = 752–9 | date = March 2012 | pmid = 22067089 | doi = 10.1093/eurheartj/ehr404 | doi-access = free }}</ref>