Unilateral pediatric "do not attempt resuscitation" orders: the pros, the cons, and a proposed approach.
A unilateral do not attempt resuscitation (DNAR) order is written by a physician without permission or assent from the patient or the patient's surrogate decision-maker. Potential justifications for the use of DNAR orders in pediatrics include the belief that attempted resuscitation offers no benefit to the patient or that the burdens would far outweigh the potential benefits. Another consideration is the patient's right to mercy, not to be made to undergo potentially painful interventions very unlikely to benefit the patient, and the physician's parallel obligation not to perform such interventions. Unilateral DNAR orders might be motivated in part by the moral distress caregivers sometimes experience when feeling forced by parents to participate in interventions that they believe are useless or cruel. Furthermore, some physicians believe that making these decisions without parental approval could spare parents needless additional emotional pain or a sense of guilt from making such a decision, particularly when imminent death is unavoidable. There are, however, several risks inherent in unilateral DNAR orders, such as overestimating one's ability to prognosticate or giving undue weight to the physician's values over those of parents, particularly with regard to predicted disability and quality of life. The law on the question of unilateral DNAR varies among states, and readers are encouraged to learn the law where they practice. Arguments in favor of, and opposed to, the use of unilateral DNAR orders are presented. In some settings, particularly when death is imminent regardless of whether resuscitation is attempted, unilateral DNAR orders should be viewed as an ethically permissible approach.
Division of Neonatal-Perinatal Medicine, Department of Pediatrics, and.
Mark R
MR
Mercurio
Peter D
PD
Murray
Ian
I
Gross
D002648:Child; D004992:Ethics, Medical; D005260:Female; D006801:Humans; D062071:Infant, Extremely Premature; D007231:Infant, Newborn; D008297:Male; D033282:Parental Consent; D010372:Pediatrics / Q000941:ethics*; D011379:Prognosis; D011788:Quality of Life; D016414:Resuscitation Orders / Q000941:ethics*
bioethics; cardiopulmonary resuscitation; children; do not attempt resuscitation orders; do not resuscitate orders; dysthanasia; ethics; futility; informed assent; informed consent; parental rights; pediatrics; resuscitation; right to mercy