Acronyms of Life, Death and Disability: CPR, DNR, DNAR,AND

Since the technique and tools to provide cardio-pulmonary resuscitation (CPR) was first used, the procedure has been a default exercise, attempted both in a hospital and non-hospital environment, for those in acute cardio-pulmonary collapse. At first, use with patients suffering cardiac arrest in electrocutions or drownings comprising generally healthy patients the success rate was high. Since then, use in patients with other illnesses leading to cardio-pulmonary arrest including those with multi-system involvement and late cancer has not been as successful in restoration of vital function. In addition, if spontaneous cardio-pulmonary activity had been restored, often there would be severe ischemic encephalopathic complications affecting neurologic recovery.

The very latest data from the largest multisite, in-hospital CPR dataset to date, was published by Peberdy et al in Resuscitation 2003 using the National Registry of CPR. (Peberdy MA, Kaye W, Ornato JP, Larkin GL, Nadkarni V, Mancinin E, Berg RA, Nichol G, Lane-Truitt T. Cardiopulmonary resuscitation of adults in the hospital: A Report of 14,720 Cardiac Arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003;58:297-308).

Rates of intact survival depend greatly on the rhythm. For shockable rhythms, the survival to discharge rate is about 35% (for pulseless Ventricular Tachycardia and Ventricular Fibrillation)
For unshockable (asystole and electromechanical dissociation) the survival is actually 10.5%, an improvement over the past. Remember, that these figures are only the “survival to discharge” and they do not tell about the consequential neurologic impairment of the patient. Also they don’t tell how many died because of another cardiac arrest which was not treated. Also the rate of resuscitation will vary between whether the patient has arrested out of the hospital and if in a hospital which hospital, which ward, what staffing, and at what hour and what day of the week

There are patients who should not be given CPR. They would be the patients who have an end-stage terminal illness or those with severe multi-system disorders where recovery of cardiac function would be less likely or only prolong the dying process. In addition, there are patients, when informed, have decided against receiving CPR. The orders, written by a physician, not to provide CPR has been termed “do not resuscitate” (DNR) or perhaps a more specific order “do not attempt resuscitation” (DNAR). These terms have left the public (patients and families) often confused regarding whether other treatments would still be provided if these orders are signed. Medical care providers have always considered DNR or DNAR as specifically related to cardio-pulmonary arrest and when written would not affect any other supportive or comfort treatments.

There is some current discussion about the use of another expression: “allowing natural death” or AND for short. This term could be used for termination of all life supportive treatments for the patient as well as resuscitation attempt for cardio-pulmonary arrest. The question can be raised whether this term might also mislead the public to assume that treatments for the comfort of patient would not be given. It is a medical principle that comfort care is never terminated in any patient including those whose life support is terminated or orders are written not to resuscitate.

Because of the consideration that CPR is over-used and applied to the wrong patients, there has been a suggestion that CPR should not be the default action but that resuscitation of a hospitalized patient should be part of a specific order on admission. If not written then there is no attempt at resuscitation. This would help eliminate a dilemma that often faces hospital nurses when a terminal patient with no DNR orders has a cardiac arrest. Should the nurse start CPR that could be a non-beneficent and futile act for this patient?

As you see, this issue is not really about semantics but about the proper treatment of a patient: providing medical standards of care ( risk vs benefits) and ethics (beneficence and autonomy). ..Maurice.