Editing Do not resuscitate (section)

== Ethics and violations ==
DNR orders in certain situations have been subject to ethical debate. In many institutions it is customary for a patient going to surgery to have their DNR automatically rescinded. Though the rationale for this may be valid, as outcomes from [[CPR]] in the operating room are substantially better than general survival outcomes after CPR, the impact on patient autonomy has been debated. It is suggested that facilities engage patients or their decision makers in a 'reconsideration of DNR orders' instead of automatically making a forced decision.<ref name="pmid26091418">{{cite journal | vauthors = Dugan D, Riseman J | title = Do-Not-Resuscitate Orders in an Operating Room Setting #292 | journal = Journal of Palliative Medicine | volume = 18 | issue = 7 | pages = 638–9 | date = July 2015 | pmid = 26091418 | doi = 10.1089/jpm.2015.0163 }}</ref>

When a patient or family and doctors do not agree on a DNR status, it is common to ask the hospital ethics committee for help, but authors have pointed out that many members have little or no ethics training, some have little medical training, and they do have conflicts of interest by having the same employer and budget as the doctors.<ref name="rubin2013">{{cite journal | vauthors = Rubin E, Courtwright A | title = Medical futility procedures: what more do we need to know? | journal = Chest | volume = 144 | issue = 5 | pages = 1707–1711 | date = November 2013 | pmid = 24189864 | doi = 10.1378/chest.13-1240 }}</ref><ref name="swetz2014">{{cite journal | vauthors = Swetz KM, Burkle CM, Berge KH, Lanier WL | title = Ten common questions (and their answers) on medical futility | language = en | journal = Mayo Clinic Proceedings | volume = 89 | issue = 7 | pages = 943–59 | date = July 2014 | pmid = 24726213 | doi = 10.1016/j.mayocp.2014.02.005 | doi-access = free }}</ref><ref name="burns2007"/>

In the [[United States]] there is accumulating evidence of racial differences in rates of DNR adoption. A 2014 study of end stage cancer patients found that non-Latino white patients were significantly more likely to have a DNR order (45%) than black (25%) and Latino (20%) patients. The correlation between preferences against life-prolonging care and the increased likelihood of advance care planning is consistent across ethnic groups.<ref name="pmid25145489">{{cite journal | vauthors = Garrido MM, Harrington ST, Prigerson HG | title = End-of-life treatment preferences: a key to reducing ethnic/racial disparities in advance care planning? | journal = Cancer | volume = 120 | issue = 24 | pages = 3981–6 | date = December 2014 | pmid = 25145489 | pmc = 4257859 | doi = 10.1002/cncr.28970 }}</ref>

There are also ethical concerns around how patients reach the decision to agree to a DNR order. One study found that patients wanted ''intubation'' in several scenarios, even when they had a Do Not Intubate (DNI) order, which raises a question whether patients with DNR orders may want CPR in some scenarios too.<ref name="capone">Capone's paper, and the original by Jesus et al. say the patients were asked about CPR, but the questionnaire shows they were only asked whether they wanted intubation in various scenarios. This is an example of doctors using the term resuscitation to cover other treatments than CPR.</ref><ref>{{cite journal | vauthors = Capone RA | title = Problems with DNR and DNI orders|url=https://www.researchgate.net/publication/274063754 | journal = Ethics & Medics | date = March 2014 | volume = 39 | issue = 3 | pages = 1–3 }}</ref><ref name="jesus"/><ref name="jesus-suppl">{{Cite journal |last=Jesus |date=2013 |title=Supplemental Appendix of Preferences for Resuscitation and Intubation... |url=https://ars.els-cdn.com/content/image/1-s2.0-S002561961300270X-mmc1.pdf|journal=Ars.els-CDN}}</ref> It is possible that providers are having a "leading conversation" with patients or mistakenly leaving crucial information out when discussing DNR.<ref name="capone"/><ref name="coleman"/>

One study reported that while 88% of young doctor trainees at two hospitals in California in 2013 believed they themselves would ask for a DNR order if they were terminally ill, they are flexible enough to give high intensity care to patients who have not chosen DNR.<ref name="periyakoil">{{cite journal | vauthors = Periyakoil VS, Neri E, Fong A, Kraemer H | title = Do unto others: doctors' personal end-of-life resuscitation preferences and their attitudes toward advance directives | journal = PLOS ONE | volume = 9 | issue = 5 | pages = e98246 | date = 2014-05-28 | pmid = 24869673 | pmc = 4037207 | doi = 10.1371/journal.pone.0098246 | bibcode = 2014PLoSO...998246P | doi-access = free }}</ref><ref>{{cite journal | vauthors = Pfeifer M, Quill TE, Periyakoil VJ | title = Physicians provide high-intensity end-of-life care for patients, but "no code" for themselves. | journal = Medical Ethics Advisor | volume = 30 | issue = 10 | date = 2014 | url = https://www.reliasmedia.com/articles/21609-physicians-provide-high-intensity-end-of-life-care-for-patients-but-no-code-for-themselves }}</ref>

There is also the ethical issue of discontinuation of an [[implantable cardioverter defibrillator]] (ICD) in DNR patients in cases of [[Futile medical care|medical futility]]. A large survey of [[Electrophysiology]] practitioners, the heart specialists who implant [[pacemakers]] and ICDs, noted that the practitioners felt that deactivating an ICD was not ethically distinct from withholding CPR thus consistent with DNR. Most felt that deactivating a pacemaker was a separate issue and could not be broadly ethically endorsed. Pacemakers were felt to be unique devices, or ethically taking a role of "keeping a patient alive" like [[Kidney dialysis|dialysis]].<ref>{{cite journal | vauthors = Daeschler M, Verdino RJ, Caplan AL, Kirkpatrick JN | title = Defibrillator Deactivation against a Patient's Wishes: Perspectives of Electrophysiology Practitioners | journal = Pacing and Clinical Electrophysiology | volume = 38 | issue = 8 | pages = 917–24 | date = August 2015 | pmid = 25683098 | doi = 10.1111/pace.12614 | s2cid = 45445345 }}</ref>

A self-report study from 1999 conducted in Germany and Sweden found that the frequency of resuscitations performed against patients' wishes (per DNR status) was as high as 32.5% among German doctors polled.<ref>{{Cite journal |last1=Richter |first1=Jörg |last2=Eisemann |first2=Martin R |date=1999-11-01 |title=The compliance of doctors and nurses with do-not-resuscitate orders in Germany and Sweden |url=https://www.sciencedirect.com/science/article/pii/S0300957299000921 |journal=Resuscitation |language=en |volume=42 |issue=3 |pages=203–209 |doi=10.1016/S0300-9572(99)00092-1 |pmid=10625161 |issn=0300-9572}}</ref>

=== Violations and suspensions ===
Medical professionals can be subjected to ramifications if they knowingly violate a DNR. Each state has established laws and rules that medical providers must follow. For example, in some states within the US, DNRs only apply within a hospital, and can be disregarded in other settings. In these states, EMTs (emergency medical technicians) can therefore administer CPR until reaching the hospital where such laws exist.<ref name="cprseattle.com">{{Cite web|title='Do Not Resuscitate' orders and bystander CPR: Can you get in trouble?|url=https://www.cprseattle.com/blog/dnrs-and-bystander-cpr-can-you-get-in-trouble|access-date=2021-09-10|website=www.cprseattle.com|language=en-US}}</ref>

If a medical professional knows of a DNR and continues with resuscitation efforts, then they can be sued by the family of the patient. This happens often, with a recent jury awarding $400,000 to the family of a patient for "Wrongful Prolongation of Life" in June 2021.<ref>{{Cite web|title=Jury Awards $400,000 in "Wrongful Prolongation of Life" Lawsuit {{!}} Physician's Weekly|url=https://www.physiciansweekly.com/jury-awards-400000-in-wrongful-prolongation-of-life-lawsuit/|access-date=2021-09-10|website=www.physiciansweekly.com|date=5 January 2021 }}</ref> Physicians and their attorneys have argued in some cases that when in doubt, they often err on the side of life-saving measures because they can be potentially reversed later by disconnecting the ventilator. This was the case in 2013 when Beatrice Weisman was wrongfully resuscitated, leading to the family filing a lawsuit.<ref>{{Cite news|last=Span|first=Paula|date=2017-04-10|title=The Patients Were Saved. That's Why the Families Are Suing.|language=en-US|work=The New York Times|url=https://www.nytimes.com/2017/04/10/health/wrongful-life-lawsuit-dnr.html|access-date=2021-09-20|issn=0362-4331}}</ref>

In the US, bystanders who are not healthcare professionals working in a professional setting are protected under the [[Good Samaritan law|Good Samaritan Law]] in most cases. Bystanders are also protected if they begin CPR and use a AED even if there is a DNR tattoo or other evident indicator.<ref name="cprseattle.com"/>

Instead of violating a DNR, anesthesiologists often require suspension of a DNR during [[palliative care]] surgeries, such as when a large tumor needs to be removed or a chronic pain issue is being solved. Anesthesiologists argue that the patient is in an unnatural state during surgery with medications, and anesthesiologists should be allowed to reverse this state. This suspension can occur during the pre-op, peri-op, and post-operative period.<ref name="cprseattle.com" /> These suspensions used to be automatic and routine, but this is now viewed as unethical. The ''[[Patient Self-Determination Act]]'' also prohibits this, as automatic suspension would be a violation of this federal order. However, it is still a common practice for patients to opt for a suspension of their DNR depending on the circumstances of the surgery.<ref>{{Cite journal|last=Jackson|first=Stephen|date=2015-03-01|title=Perioperative Do-Not-Resuscitate Orders|url=https://journalofethics.ama-assn.org/article/perioperative-do-not-resuscitate-orders/2015-03|journal=AMA Journal of Ethics|volume=17|issue=3|pages=229–235|doi=10.1001/journalofethics.2015.17.3.nlit1-1503|pmid=25813589|issn=2376-6980|doi-access=free}}</ref>

Ethical dilemmas on suspending a DNR occur when a patient with a DNR attempts suicide and the necessary treatment involves ventilation or CPR. In these cases, it has been argued that the principle of beneficence takes precedence over patient autonomy and the DNR can be revoked by the physician.<ref>{{cite journal|vauthors=Humble MB|date=November 2014|title=Do-Not-Resuscitate Orders and Suicide Attempts: What Is the Moral Duty of the Physician?|journal=The National Catholic Bioethics Quarterly|volume=14|issue=4|pages=661–71|doi=10.5840/ncbq201414469}}</ref> Another dilemma occurs when a medical error happens to a patient with a DNR. If the error is reversible only with CPR or ventilation, there is no consensus if resuscitation should take place or not.<ref name="pmid23630240">{{cite journal|vauthors=Hébert PC, Selby D|date=April 2014|title=Should a reversible, but lethal, incident not be treated when a patient has a do-not-resuscitate order?|journal=CMAJ|volume=186|issue=7|pages=528–30|doi=10.1503/cmaj.111772|pmc=3986316|pmid=23630240}}</ref>