Allow Natural Death: “Do Not Resuscitate” Orders
Kathryn A. Koch, MD
Abstract: Limitation of treatment decisions remain problematic despite
both ethical and legislative endorsement of the patient’s right to choose a
course of treatment. There is broad variation in public knowledge and
attitudes about what is and is not possible at the margin between life and
death. There is an illusion of efficacy of cardiopulmonary resuscitation
(CPR). Originally proposed for witnessed collapse of circulation in the
Operating Room, CPR is now applied regardless of the circumstances
through a presumption of consent. Do Not Resuscitate (DNR) orders
occupy a unique niche in medical orders. They are orders to withhold
that specific intervention. Discussing the option not to resuscitate or
to limit treatment can be difficult for patient, family, and caregiver
alike. If patients are unable to make their own decisions, a proxy or
surrogate decision-maker needs to be identified which adds another level
of complexity, particularly if the patients never discussed their wishes
with their surrogate. Some practical suggestions are made to facilitate
communication about these difficult choices. It must be clear that a
DNR order by itself is not an order to withhold other treatments and
is not a death sentence. It is a choice for dignity, respect, and comfort
if other treatments fail.
Introduction: Oscar the Cat
The schizophrenic quality of unrealistic expectations in
treatment of death and dying was exemplified by the media
reports in the last week of July, 2007. Oscar’s (a cat) activities
were published in the New England Journal of Medicine and
quickly became national news.1,2 Oscar accurately predicted
25 deaths (which took place within the next 4 hours) at a
nursing home in Providence, Rhode Island. Making his own
independent rounds, he identified patients who will die shortly
by laying down with them. This behavior is now viewed by
the staff as a sign to notify family to assemble. Joan Teno, a
member of the SUPPORT investigator group and who treats
patients at that nursing home, was reported to say that Oscar
was better at predicting death than staff. 2,3
Oscar’s activities hit prime time. He made it into Jay Leno’s
nightly monologue. He even was mentioned on the NBC
Nightly News. An email about Oscar was quoted by Bryan
Williams that said, “Has anyone considered the possibility
that Oscar is killing those patients?” 4
In addition, two accompanying “perspective” articles in that
issue of the Journal reviewed factors that contribute to late
referral and possibly under-utilization of hospice services. 5,6
That same contrary week had begun with a front-page
article in Newsweek with the headline: “This Man Was Dead.
He Isn’t Anymore. How Science is Bringing more Heart-At-
tack Victims Back to Life”.7 In this lay public discussion of
inducing hypothermia in victims of post-cardiac arrest to
improve neurologic outcome, the most accurate statement
by the authors was that “Dying turns out to be almost as
complicated as living”.7
Address Correspondence to: Kathryn A. Koch, MD, University of
Florida, Shands-Jacksonville. Email: kathryn.koch@jax.ufl.edu.
www . DCMS online . org
Illusion of Efficacy of CPR
Dying can be quite complicated, whether one chooses to
fight until the bitter end, regardless of pain and suffering,
or whether one chooses a path with different goals, hope-
ful for palliation and comfort. And therein lies the rub. As
a multicultural society fascinated with life and in denial of
death, permitting a death to occur naturally is suspect and
out of character.
Outcome of cardiopulmonary resuscitation (CPR) is er-
roneously, but commonly, held to be good by the lay public.
Some blame this disconnect on television. In a review of all
episodes of the television programs ER and Chicago Hope
during the 1994-1995 season, and 50 consecutive episodes of
Rescue 911 broadcasts over a 3 month period in 1995, 75% of
patients survived the immediate arrest, and 67% apparently
survived to hospital discharge.8 The majority of these patients
were victims of trauma and were young.
The Europeans have also examined this question. The
outcomes of cardiac arrest in 70 episodes of Spoed (a popular
Flemish medical drama in Belgium) were more realistic,
more age-appropriate, and only 19% of patients survived
the resuscitation attempt.9 The authors postulated that any
impressive examples of success might be more important to
the lay public imagination than overall success rate. They
also proposed that television depiction of cardiopulmonary
resuscitation, which demonstrates that treatment does not
stop simply because the patient is dead, supports the “illu-
sion of efficacy”. Otherwise, why would this treatment be
given at all? Upon review of 64 episodes of three popular
British medical dramas, Casualty, Cardiac Arrest, and Med-
ics, only 62% of victims of full cardiac arrest underwent
CPR, and only 8 attempts were successful.10 These authors
concluded that widespread public optimism for resuscitation
outcome was not based on the fairly realistic depiction seen
on British television.
Yet, inappropriate optimism does seem to exist. In a random
distribution of 400 surveys to 8 North Carolina church con-
gregations, almost all of the 269 respondents had unrealistic
expectations of outcome of CPR. As a group they indicated
an expected survival rate of 65% for CPR, with younger re-
spondents as a group reporting a higher probability of good
outcome; television exposure for older respondents was also
associated with expectation of better outcome.11 In a random
sample of 820 Belgian secondary students, the consumption
of medical television drama was related to an overestimation
of survival outcome following CPR.12
A survey of 100 patients 70 years of age or older revealed
that 81 respondents (81%) believed that the chance of sur-
viving in–hospital CPR and leaving the hospital alive was at
least 50%, and a quarter (23%) of those respondents expected
their outcome to be at least 90% probability of survival to
hospital discharge.13 The largest proportion of these patients
received information affecting their decision from the tele-
vision as opposed to other sources, such as their physician.
The clinician familiar with the patient’s specific medical
Northeast Florida Medicine Supplement January 2008 13
situation, would be the ideal person to educate the patient,
but finding the time to identify and clear up disinformation
is itself problematic.
Another level of potential confusion about DNR orders
occurs when patients (or their families) are offered menu
choices in treatment indiscriminately. This is best exemplified
by the patient who refuses intubation and mechanical ventila-
tion should he/she fail other interventions, yet requests full
cardiac resuscitation. Such individuals may not understand
that refractory respiratory insufficiency is likely to lead to
cardiac arrest. This predictable series of physiologic events
must be discussed. If the patient doesn’t receive intubation
and mechanical ventilation to prevent that deterioration,
what physiologic purpose is there to resuscitation when
the heart can’t take it any more? Patients or their families
requesting such an order require time for further explanation
and education. Their decision is not well informed and their
expectations are unrealistic.
A more realistic decision would be to attempt intubation
to prevent death if possible, but if death still occurs, then
withhold cardiac resuscitation. Address the goals of treat-
ment, what is possible and what is not given the medical
circumstances and available treatment, how the goals can or
cannot be achieved, and then describe what choices on the
menu of options match those goals best (Table 1).
DNR Orders are Unique
DNR orders are a unique phenomenon in that they are
orders not to intervene, or not to take action: a “negative” or
“passive” order set. Most medical orders are direction to take
some action and thus “positive” or “active”. Unless a DNR
order is written, consent for resuscitation is presumed.
There are good medical grounds for such an attitude.
The patient has collapsed and is unable to make decisions
to consent or object to treatment. Prompt action optimizes
outcome. The longer action is delayed, the longer the patient’s
hypoxia time, the greater opportunity for accumulation of
toxic metabolites. If delayed action is successful at returning
spontaneous circulation, survivors are at greater risk for nega-
tive consequences of reperfusion injury.
The greatest risk is to brain recovery, thus the exploration
of post-resuscitation interventions to improve neurologic
outcome.7,14,15 Death is clearly a process rather than an event,
given our current medical knowledge and capability. Act now or
it may be too late — the fate resulting from delay might even
be worse than death. Dying is as complicated as living.7
The presumption of consent for resuscitation was confirmed
by the 1983 President’s Commission.16 The State of Florida
requires a stated objection to a standard medical intervention,
if the provider acts as any reasonably prudent person would
have acted under same or similar circumstances.17
Thus, CPR has become a standard of care. It can be imple-
mented by any bystander, ideally as quickly as possible. See
Table 2 for some practical problems in not providing CPR.
DNR Order Does Not Limit Other Treatment
One of the practical problems in establishing a DNR order
is achieving the mutual understanding that a DNR order is
neither a “Do Not Treat” nor a “Comfort Measures Only”
order. It is a “No CPR” order – a “Do Not Allow Resuscitation”
order – ideally with clear direction as to what “resuscitation”
14 January 2008 Northeast Florida Medicine Supplement
Table 1 Practical Suggestions in
Discussing DNR Decisions
• Educate to dispel inappropriate optimism
• Offer options which may include limitation of treatment
and should include discussion of circumstances where
limitation would be appropriate
• Do not offer menu choices without education, address
goals of treatment, and then show how goals affect specific
choices
• Be specific about what treatment will be held, what treat-
ment will be given. Differentiate this decision from a “Pull
the Plug” decision. Detail discussion in writing in chart.
Be sure orders are clear
• When discussing decision with a proxy or surrogate, focus
on what would be the patient’s choice and what would be
in the patient’s best interest
• Develop a plan to communicate decision to other family members
and to other caregivers (consider outpatient DNR order)
Table 2 Problems in Establishing &
Maintaining DNR Decisions
• Lay public illusion of efficacy of CPR
• Unique niche in medical orders as an order to withhold
• Presumed consent for resuscitation
• The margin of the DNR order can easily become blurred.
There are concerns that other treatment will be withheld
• Failure to address end of life issues with the patient while
he/she is still able to make their own decisions
• Identification of decision-maker for the patient who lacks
decisional capacity
• Failure to communicate chosen level of care within family
and among caregivers over time
is to be held (or given). The intent of a DNR order is to limit
aggression at the margin between life and death, particularly
where aggressive measures have already failed (or will probably
fail) to prevent deterioration to the events of death.
DNR is a “negative” statement. Reverend Chuck Meyer
from Texas proposed the terminology of “Allow Natural Death”
(AND) as a more positive and more comforting expression of
the same decision.18 Empirical report from Kentucky where
some institutions have adopted this alternative wording has
been positive.19 Some are convinced that use of “AND” as
opposed to “DNR” as terminology can help change the
experience of making decisions about facing death in a very
positive way.20 The challenge is that the expression “AND”
is less explicit and more vague than “DNR”, thus even more
likely to mislead.21
Be aware that some individuals do not understand that
interventions like dialysis and mechanical ventilation are
www . DCMS online . org
“life support”. Also recognize that some individuals believe
that because a patient is on “life support”, he/she cannot die.
Minimize confusion about the plan by careful documentation
in the medical record.
Proxy/Surrogate Decision-makers
Another practical problem with establishing a DNR order
is that the decision-maker may not be the patient. This person
may view a DNR decision as a decision to “pull the plug”. To
this end, a separate form for termination of treatment may be
useful. The DNR decision and the “pull the plug” decision
must be distinguished; the latter not possible until the former
has already been decided. The surrogate should be reminded
by the clinician that their job and responsibility is to make
the decision the way they think the patient would choose
or in a way that would meet the patient’s best interest given
the circumstances. To facilitate the decision, help the family
members imagine an empty seat at the table or in the room
for the patient to be present, at least in spirit.
The ethical principle of respect for persons informs a DNR
decision and the principle of respect for life informs a “full
code” decision. The principles of beneficence, nonmaleficence,
and autonomy could each be in favor of either decision,
depending on the circumstances (Table 3). Acknowledge
that you know they do not want to lose their loved one.
Offer a limitation to aggressiveness as an option when other
treatment is failing or is likely to fail. If the situation is one
where dying and suffering are being prolonged and there is no
realistic expectation that the patient can recover to functional
independence, offer to adjust treatment to a primary goal of
comfort. Offer to ensure that the loved one is treated with
respect as they die.
Raising End of Life Issues with Patient
The biggest practical problem with DNR orders is the fail-
ure to raise end of life issues with patients and explore all of
their options, when a diagnosis is made. Options to address
might include comfort measures in addition to treatments
intended to cure or to at least palliate. The timing ideally
ought to be when the patient is well enough to think clearly
and certainly should be prompted by recognition of medical
circumstances which predict a poor outcome. Limitation of
aggressive medical interventions should be considered if the
clinician can imagine that the patient will be dead within
the next 6-12 months.
The SUPPORT study showed clearly that we do not pay
good attention to matching patient preferences to predicted
medical outcomes.22 This requires a frank discussion of
death and the end of life and should be initiated when the
patient is still well enough to consider how he/she wishes
to face the situation. The objective is to optimize quality of
remaining life, to help the patient choose new goals. It’s not
about losing hope, it’s about changing what to hope for. A
practical tool is the CARING criteria, developed to identify
patients on hospital admission with whom to address end
of life (EOL) issues, who might benefit from a palliative
approach to care. 23,24 (Table 4, p.16)
It is within this context that terms such as “allowing nature
to take its course” or “allowing natural death” may be useful
during dialogue. Whatever terms are used, it should be ex-
plicit what will and will not be done. If the clinician is at all
www . DCMS online . org
Table 3 Ethical Principles Informing
End of Life Decisions
“Full Code”
• Respect for life
• Beneficence: Of course, our goal is to preserve life
• Non-Malefience: It would be a harm to die
• Autonomy: Of course, patient would want to live
DNR
• Respect for persons
• Beneficence: If we are not able to preserve life,
then it would be good to minimize the suffering
• Non-maleficence: If the treatment is worse than
the disease, then it has become a harm
• Autonomy: Would the patient choose to fight
regardless of suffering, or let go
concerned about full clarity, consider reviewing the resulting
written order carefully with the decision-maker. This will make
as certain as possible that there is true mutual understanding
about what will or will not be done in an emergency, and
what will or will not be done in the meantime.
As in any situation where the physician is informing the
patient of options so he/she can make an intelligent decision
among potential choices, any consideration about allowing
natural death requires a discussion of comfort and caring at
the end of life. Palliative care, hospice, and/or chaplain con-
sultation may all be beneficial. Patients may be concerned that
they not suffer, that they be as independent as possible for as
long as possible, and that we will share those goals.
Communication of Decisions on Level of Care
The issue of communication about level of care, or “code
status”, between patient/family and multiple caregivers over
time is one that has not been effectively solved. Institutions
are required to enquire about advance directives on admis-
sion, but an advance directive is not a DNR order itself. A
DNR order at one institution may not be considered valid
at another, a prior DNR order on one admission may not be
considered durable for the next.
Discharge planning for a patient who was DNR during
a hospitalization should include planning about code status
after discharge. In the State of Florida, there is a specific order
for outpatient DNR (DNRO) which can be implemented if
desired.25 At the author’s institution, this is the only order
that is considered durable from one admission to the next.
In the absence of a DNRO, complete reevaluation of level of
care and code status must be made if the patient returns to
the hospital. He/she will be assumed to be “full code” until
the issue can be revisited.
Advance communication about code status ought to
minimize confusion and concern, but this is problematic.
Only 13/209 (6.2%) metastatic cancer patients referred for
outpatient palliative radiation treatment had documented
reference to their code status on referral.26 A retrospec-
tive review of 392 cardiac arrest 9-1-1 calls to Emergency
Medical Services in Seattle revealed that 139 (35%) residents
had DNR orders, and 29 (21%) of these patients actually
received resuscitation due to problems in communication of
the DNR orders.27
Northeast Florida Medicine Supplement January 2008 15
 Table 4 CARING24
C: Primary diagnosis of cancer
A: Two admissions for chronic illness in the past year
R: Resident in nursing home
I: Intensive care unit admission with multi-organ dysfunction
N: Noncancer hospice patient with 2 or more hospice criteria
G: Refer to hospice guidelines/NHPCO
(Table adapted from information National Hospice and Palliative Care
Organization website/www.nhpco.rog)
Unless the patient personally instructs the clinician about
their DNR status, in the State of Florida the patient must be
found by 2 physicians to be end stage or terminal and un-
able to make his/her own decisions (and unlikely to recover
that ability in the future), and the family must concur that
limitation of treatment is appropriate, before a DNR order
can be recorded.28 This leads to problems when patients ar-
rive in extremis unable to make their own decisions, little is
known by available caregivers about them, and no family or
other knowledgeable caregiver can be contacted immediately.
Implementing this process in a medical emergency is difficult,
which may lead to treatment against the patient’s previously
stated wishes. An informatics mechanism using a computer-
ized search for keywords in prior hospital dictated reports is
theoretically possible to help identify patients with prior DNR
orders on previous admissions.29 The DNRO could also be
used as a vehicle to notify about such wishes from admission
to admission and caregiver to caregiver.
In the absence of discoverable family or friends willing to
step forward as proxy decision-maker, the State of Florida has
established a mechanism to appoint a proxy to speak for the un-
friended patient who is unable to make his own decisions.28
DNR: A Death Sentence?
In reviewing the outcome of patients who become DNR
after admission to an ICU service, it was discovered that
most died during that hospitalization, but that the DNR
decision was not a death sentence. Some patients were even
discharged alive.30 However, a retrospective review of 13,337
consecutive stroke admissions at 30 hospitals, revealed that the
2,898 (22%) of patients who had DNR orders established at
any time during their hospitalization had a higher propensity
adjusted rate of death than those who had no such orders.31
Some oncologists have voiced a concern that some patients
may die because they have DNR orders, as opposed to having
a DNR order established in anticipation of death.32
Patients may even choose to not limit treatment because
they are concerned that this choice may limit other aspects
of their treatment; that they will be treated differently.33
It must be very clear that a DNR order by itself does not
limit treatment in any other way. Whenever a DNR order is
established, concerns about how to handle other aspects of
aggressive care should be addressed.
This issue is best exemplified over the issue of DNR in
the Operating Room (OR). DNR patients may be potential
candidates for certain surgical procedures, particularly
palliative interventions. Resuscitation for witnessed arrest in
16 January 2008 Northeast Florida Medicine Supplement
the OR was exactly what Kouwenhoven had in mind when he
first published on closed chest cardiac massage.34 The policy
on this issue has been established. The American Society of
Anesthesiologists in conjunction with the American College of
Surgeons formalized the policy of “required reconsideration”
with guidelines initially approved in 1993.35
DNR orders will not be automatically rescinded for a trip
to the OR, although the patient/surrogate may choose that
as an option. An alternative option is to leave the DNR order
in place with a clear outline of goals and objectives of said
operation or with a detailed list of procedures and interven-
tions that are permitted (or refused). A solution to the level
of treatment that is both patient-specific and situation-spe-
cific needs to be sought.36 See Table 5 for some practical
tools in such difficult discussions. It has been proposed that
continuation of a DNR order into the OR is analogous to
performing surgery on Jehovah’s Witnesses who have refused
a life-saving transfusion.37
Table 5 Tools & Tips for Difficult Discussions
• Set an appointment with patient or decision-maker and
any folks they wish to also be present
• Block the time to talk without interruption
• Select meeting location for privacy
• Bring another caregiver, such as a nurse, to witness and to
help confirm there is mutual understanding
• Be prepared to listen
• Identify the decision-maker if you don’t already know.
Introduce everybody
• Fire a “warning shot”, eg: “We have a difficult situation to
face….”
• Start the conversation by asking what they already know
so you can clear up any misinformation up front
• State medical facts of situation in simple terms
• Be prepared to face tears and even anger
• If the patient is making their own decision, the rest of the
family is there to support them in that decision
• If there is another decision-maker, remind them that their
job is to try to make the decision the way they think the
patient would want it made
• Seek a decision on goals in medical treatment and then
confirm the medical treatments that would be included to
attempt to achieve those goals
Conclusion
Lack of comprehension of the risks and benefits of attempted
resuscitation are overshadowed by inappropriate optimism
that independent survival will be the outcome of any attempt.
This misunderstanding, if uncorrected, may contribute to
confusion. Persons who hold such erroneous beliefs need
more education to make a fully informed decision but, in fact,
www . DCMS online . org
DNR decisions are made in the absence of better knowledge
all of the time.
As long as a DNR order is understood to withhold specific
treatment if other treatment fails, there should be no change
in the level of care of the patient unless additional decisions
to reduce interventions are made.
As Oliver Wendell Holmes Sr. aptly said, “To cure rarely,
to heal sometimes, to comfort always.” Oliver Wendell Hol-
mes Sr. (1809-1894. US physician, poet, humorist, father
of Oliver Wendell Holmes Jr the jurist, Dean of Harvard
Medical School)
Acknowledgement: Linda Suydam for her expert editorial assistance.
References
1. Dosa DM. A Day in the Life of Oscar the Cat. N Engl J Med.
2007;357:328-9.
2. Oscar the Cat Predicts Nursing Home Deaths. Associated
Press, 7/25/07, www.foxnews.com accessed 7/26/07.
3. The SUPPORT investigators. SUPPORT: study to understand
prognoses and preferences for outcomes and risks of treatment.
Study design. J Clin Epidemiol. 1990;43(Supple):1S-123S.
4. NBC Nightly News, 7/28/07.
5. Gazelle, G. Understanding Hospice – an Underutilized Option
for Life’s Final Chapter. N Engl J Med. 2007;357:321-4.
6. Wright AA, Katz IT. Letting Go of the Rope – Aggressive
Treatment, Hospice Care, and Open Access. N Engl J Med.
2007;365:324-7.
7. Adler J, Philips M, Raymond J, Scelfo J. Back from the Dead.
Newsweek. July 23, 2007, 42-49.
8. Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation
on television. Miracles and misinformation. N Engl J Med.
1996;334:1578-82.
9. Van den Bulck J, Damiaans K. Cardiopulmonary resuscitation
on Flemish television: challenges to the television effects
hypothesis. Emerg Med J. 2004;21:565-7.
10. Gordon PN, Williamson S, Lawler PG. As seen on TV:
observational study of cardiopulmonary resuscitation in British
television medical dramas. BMJ. 1998;317:780-3.
11. Jones GK, Brewer KL, Garrison HG. Public Expectations of
survival following cardiopulmonary resuscitation. Acad Emerg
Med. 2000;7:48-53.
12. Van den Bulck JJ. The impact of television fiction on public
expectations of survival following inhospital cardiopulmonary
resuscitation by medical professionals. Eur J Emerg Med.
2002;9:325-9.
13. Adams DHJ, Snedden DP. How misconceptions among
elderly patients regarding survival outcomes of inpatient
cardiopulmonary resuscitation affect Do-Not-Resuscitate
orders. J Am Osteopath Assoc. 2006;106:402-4.
14. Hypothermia after cardiac arrest study group. Mild therapeutic
hypothermia to improve the neurologic outcome after cardiac
arrest. N Engl J Med. 2002;346:557-63.
15. Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose
survivors of out-of-hospital cardiac arrest with induced
hypothermia. N Engl J Med. 2002;346:557-63.
16. President’s Commission for the Study of Ethical Problems in
Medicine and Biomedical and Behavioral Research: Deciding
to forego life-sustaining treatment: Report on the ethical,
medical and legal issues in treatment decisions. Washington,
US Government Printing Office, 1983.
17. Title XLIV on Civil Rights, Chapter 765 on Health Care
www . DCMS online . org
Advance Directives, and Title XLV on Medical Malpractice,
Chapter 766 on Medical Consent, and Chapter 768 on
Negligence, part I General Provisions, section 768.13 Good
Samaritan Act. The 2007 Florida Statutes. www.leg.state.
fl.us/statutes/ accessed 7/31/7.
18. Meyer C. Allow Natural Death – An Alternative to DNR?
www.hospicepatients.org/and.html/ accessed 7/31/7.
19. Knox, C, Vereb JA. Allow Natural Death: A more humane
approach to discussing end-of-life directives. J Emerg Nurs.
2005;31:560-1.
20. Cohen RW. A Tale of Two Conversations. Hastings Cent Rep.
2004;34(3):49.
21. Chessa, F. “Allow Natural Death” – Not so fast. Letters to
the Editor. Hastings Cent Rep. 2004;34(5):4.
22. SUPPORT Principle Investigators. The Study to Understand
Prognoses and Preferences for Risks of Treatment. (SUPPORT).
JAMA. 1995;274:1591-8.
23. Fischer SM et al. A practical tool to identify patients who may
benefit from a palliative approach: the CARING criteria. J
Pain Symptom Manage. 2006;31:285-92.
24. Shannon RP, Gwin DK, Colon-Otero G, Howick PH. The
Palliative Care Consultation service: optimizing quality of life
when quantity of life is limited. NE Fl Med. 2006;57:35-9.
25. Title XXIX Public Health. Chapter 401 Medical
Telecommunications and Transportation. 401.45: Denial
of emergency treatment; civil liability. The 2007 Florida
Statutes. www.leg.state.fl.us/statutes/ accessed 8/1/07. Florida
Department of Health from 1896.
26. Bradley NM, Sinclair E, Danjoux C et al. The do-not-resuscitate
order: incidence of documentation in the medical records
of cancer patients referred for palliative radiotherapy. Curr
Oncol. 2006;13:47-54.
27. Becker LJ, Yeargen K, Rea TD et al. Resuscitation of residents
with do not resuscitate orders in long term care facilities.
Prehosp Emerg Care. 2003;7:303-6.
28. Title XLIV Civil Rights. Chapter 765 on Health Care
Advance Directives. The 2007 Florida Statutes. www.leg.
state.fl.us/statutes/ accessed 8/1/07.
29. Aronsky D, Kasworm E, Jacobson JA et al. Electronic screening
of dictated reports to identify patients with do-not-resuscitate
status. J Am Med Inform Assoc. 2004;11:403-9.
30. Koch, KA, Rodeffer HD, Wears RL. Changing Patterns of
Terminal Care Management in an Intensive Care Unit. Crit
Care Med. 1994;22:233-43.
31. Shepardson LB, Youngner SJ, Speroff T, Rosenthal GE.
Increased risk of death in patients with do-not-resuscitate
orders. Med Care. 1999;37:727-37.
32. Sulmasy DP. Do patients die because they have DNR orders,
or do they have DNR orders because they are gong to die?
Med Care 1999;37:719-21.
33. Phillips RS, Wenger NS, Teno J et al. Choices of seriously ill
patients about cardiopulmonary resuscitation: correlates and
outcomes. SUPPORT Investigators. Study to understand
prognoses and preferences for risks of treatment. Am J Med.
1996;100:128-37.
34. Kouwenhoven WB, Jude JR, Knickerbocker GG: Closed
chest cardiac massage. JAMA. 1960;173:1064-7.
35. Ewanchuck M, Brindley PG. Ethics review: perioperative
do-not-resuscitate orders – doing “nothing” when “something”
can be done. Critical Care. 2006;10:219.
36. Craig, DB, Webster GC. Do Not resuscitate orders---managing
the dilemma. Can J Anaesth. 1998;45:R160-71
37. Walker RM. DNR in the OR. Resuscitation as an operative
risk. JAMA. 1991;266:2407-12.
Northeast Florida Medicine Supplement January 2008 17