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With medicine’s increasing capabilities, situations arise in which possible interventions will not serve the patient’s or the family’s goals of care. Under such circumstances, the decision to forgo treatment, even potentially lifesaving treatment, may be appropriate. This chapter discusses one means of limiting treatment: do-not-attempt-resuscitation (DNAR) orders. It describes the historical development of DNAR orders, outlines the process of writing such orders, and explains why they should generally not be written unilaterally. The related issues of family presence during resuscitation and DNAR orders in the operating room and outside the hospital are also reviewed.


Do-not-resuscitate (DNR) orders developed out of the recognition that cardiopulmonary resuscitation (CPR) lacks efficacy in certain patient populations and that a formal process of advance planning was needed. Although modern CPR was initially developed for patients suffering anesthesia-induced cardiac arrest, it became the standard of care for cardiac arrest in hospitalized patients regardless of their underlying diagnoses. Experience, however, demonstrated that the effects of CPR were often transient. In some institutions, covert decision-making processes evolved to withhold or limit resuscitation efforts. Hospitals developed DNR policies in the 1970s to address the need for both a decision-making process and a means to communicate these decisions.1

There are limited data in the pediatric literature regarding the efficacy of CPR in hospitalized patients. In reviewing the literature it is important to focus on patient-centered outcomes. A retrospective review of data from the National Registry of Cardiopulmonary Resuscitation (NRCPR) found that 52% of children who experienced an in-hospital cardiac arrest resuscitation (pulseless cardiac arrest requiring chest compressions, defibrillation, or both, that elicited an emergency resuscitation response and resulted in a resuscitation record) had return of spontaneous circulation for greater than 20 minutes and 27% survived to hospital discharge. Of the children who survived to discharge, 65% had a good neurological outcome defined as a Pediatric Cerebral Performance Category of normal functioning, mild disability, or moderate disability.2

A retrospective review of in-hospital cardiac arrests in 15 children’s hospitals within the Pediatric Emergency Care Applied Research Network (PECARN) found that 48.7% of patients between 1 day and 18 years of age who received greater than 1 minute of chest compressions and had return of circulation for at least 20 consecutive minutes survived to hospital discharge.3 This compares to 51% in the NRCPR study.2 Using different criteria, the PECARN investigators found a higher rate of good neurological outcomes; among survivors who had prearrest and discharge Pediatric Cerebral Performance Category scores available, 94.3% had discharge scores of normal or mild disability or no change in score.3

Information regarding the efficacy of CPR within specific diagnostic categories is even more limited. The PECARN study found pre-existing hematologic, oncologic, or immunologic disorders and pre-existing genetic or metabolic disorders were associated with increased hospital mortality.3

Based on the limited ...

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