Do-not-resuscitation orders:: when, why and how can they be done?

The main goal of medical treatment is to benefit patients by restoring or maintaining their health. Nevertheless, prolonging life at all costs is not acceptable. Cardiopulmonary resuscitation (CPR) should not be started in all cardiac arrest case, but rather if it is indicated. The competent patient, by means of a valid informed consent, is entitled to accept or refuse any diagnostic or therapeutic procedure (except for that required by law), including CPR in case of a cardiac arrest (CA). Deliberation on CPR should be started with the patient if he or she has a high likelihood of suffering CA, within a process of advanced care planning. This is done ideally in an out-patient setting and mainly when the patient suffers a chronic illness or a potentially fatal severe condition. Other guidelines recommend starting CPR discussions with all adults admitted to hospital. Some neurological diseases in which it is recommended are end-stage dementia, progressive degenerative diseases and serious brain lesions. If the patient or his legal surrogate does not accept CPR, a do-not-attempt resuscitation order (DNAR) should be entered in his/her medical record. The DNAR order validity is based on following hospital or institutional rules. The DNAR order should be reviewed under special circumstances.