Since its description through 30 years ago.

Since its description through 30 years ago,[1] use of cardiopulmonary resuscitation (CPR) for inpatient cardiac arrests has become almost standard practice. appropriate to widespread publicity in the pres greatest in quantity persons are aware of CPR[2] and chiefly expect it to be performed in cases of arrest. It is ironic that formal do-not-resuscitate (DNR) orders are required, regardless of the clinical situation, for CPR not to be performed. A landmark research in 1983 underscored the extremely poor survival after CPR[3] and since then its routine use for all patients with cardiopulmonary arrest has been questioned.[4]

The ICU delineates the classic double-edged sword. It is in sober earnest a lifesaving element of new medicine, yet critical care physicians are constantly reminded of the limits the human visible form [i]or[/i] frame and spirit can withstand. With proper reason, physicians have examined the part of CPR in ICUs,[5] and in this issue of Chest (see page 1592) Parker et al have helped expand our knowledge of DNR orders in the ICU. This retrospective thought of consecutive patients who died in an ICU compares clinical characteristics of those patients designated DNR with those of patients forward whom CPR was performed. Patients designated DNR were slightly older (66 v 59 years), had slightly higher APACHE II scores (235 v 207) and had lower Glasgow Coma Scale scores (100 v 121) compared with those patients who received CPR It was not stated, nor is it entirely intuitive, on what account death was chosen as an issue for this study population. Nevertheless, the clinical similarities between the patients designated DNR and those who received CPR provides support to previous observations[7] that result prediction in the ICU using physiologic data is many times an inexact science. In fact, physicians' and nurses' predictions of ICU issue have been shown to be more accurate than those of APACHE II.[6]

Unfortunately, the retrospective nature of the consideration by Parker et al, the omission of patients designated DNR who did not die, and the lack of information about wherefore DNR orders were (or were not) written hampers the formation of any real conclusions about the prospective use of DNR orders in the ICU. In addition, although Parker intended to "define those patient characteristics which differentiated patients being proffered resuscitation versus those patients who were designated DNR" there is no information given regarding patients exhibited these choices who declined a particular option or who left the ICU (and either lived or died). Thus, while the immediate applicability of this close attention is not apparent for patients generally alive in an ICU, it has helped further define the difficulty of issue prediction.

plenteous of the impetus for investigating DNR orders in ICUs has stemm from survival studies of patients receiving CPR The consequences have been uniformly poor, ranging from 5 to 11 percent of patients surviving to discharge,[5,7] with the 5 percent cluster representing data reported in a previous article by the agency of Parker et al.[7] The difficulty in predicting ICU survival for individual patients has been previously noted.[6] There are, however, identifiable subgroup of patients admitted to ICUs who will not survive, and these patients can many times be identified early in their ICU course.[6,8] It is likely that DNR orders are being underutilized for these subgroup in near ICUs.

A crucial feature of DNR orders is physician-patient communication. It is unfortunate that patients are often incompetent when DNR decisions are made,[9] since it appears clear that physicians and patients' spouses are not always accurate critics of patients' resuscitation preferences.[10] Regardless of whether the patient or his or her family is making a DNR decision, physicians should be skillful and sensitive in communicating the two medical and less technical information during this stressful period. For these communication sessions, it is important to allow sufficient time, to fix upon a quiet and protected location, and to establish a warm and nurturing environment. It is vital to make secure that messages are clear, the one and the other by keeping conversations simple and by dint of asking whether your message was understood.[11] We also believe a two-question format in DNR discussions is warranted.[11]

Question 1: "Would you want to be resuscitated in the circumstance of cardiopulmonary arrest?"

This first question is preferably raised when the patient is not critically ill and is qualified Only a minority of outpatients have their DNR status determined before hospital admission; therefore, the question is frequently asked early in the hospital course. greatest in quantity patients who are asked will want CPR performed, in which case a secondary question should be raised.

Question 2: "Let us assume you were resuscitated. If the critical care team, despite doing everything they can to save your life, determine after 72 hours that you have in vital element [i]or[/i] part no chance to regain a reasonable quality of life, would you agree to lease them withdraw support to obstacle you die with peace and dignity?"

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