title: What is the true definition of a "Do-Not-Resuscitate" order? A Japanese perspective.
abstract: BACKGROUND
  Japan has no official guidelines for do-not-resuscitate (DNR) orders. Therefore, we investigated the effect of DNR orders on physician decision making in relation to performing noncardiopulmonary resuscitation (CPR) and CPR procedures.
  
  
  METHODS
  A case-scenario-based questionnaire that included a case of advanced cancer, a case of advanced dementia, and a case of nonadvanced heart failure was administered to physicians. The questions determined whether physicians would perform different non-CPR procedures and CPR procedures in the presence or absence of DNR orders. The number of non-CPR procedures each physician would perform and the number of physicians who would perform each non-CPR and CPR procedure in the absence and presence of DNR ocrders were compared. Physicians from three Japanese municipal acute care hospitals participated.
  
  
  RESULTS
  We analyzed 111 of 161 (69%) questionnaires. Physicians would perform significantly fewer non-CPR procedures in the presence of DNR orders than in the absence of DNR orders for all three case scenarios (median [interquartile range] percentages: Case 1: 72% [45%-90%] vs 100% [90%-100%]; Case 2: 55% [36%-72%] vs 91% [63%-100%]; Case 3: 78% [55%-88%] vs 100% [88%-100%]). Fewer physicians would perform non-CPR and CPR procedures in the presence of DNR orders than in the absence of DNR orders. However, considerable numbers of physicians would perform electric shock treatment for ventricular fibrillation in the presence of DNR orders (Case 1: 26%; Case 2: 16%; Case 3: 20%).
  
  
  CONCLUSIONS
  DNR orders affect physician decision making about performing non-CPR procedures. Although some physicians would perform CPR for ventricular fibrillation in the presence of DNR orders, others would not. Therefore, a consensus definition for DNR orders should be developed in Japan, otherwise DNR orders may cause harm.
authors.affiliation: Department of Internal Medicine.
authors.forename: Eiji
authors.initials: E
authors.lastname: Hiraoka
authors.affiliation: Department of Emergency Medicine.
authors.forename: Yosuke
authors.initials: Y
authors.lastname: Homma
authors.affiliation: Department of Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan.
authors.forename: Yasuhiro
authors.initials: Y
authors.lastname: Norisue
authors.affiliation: Department of Internal Medicine.
authors.forename: Takaki
authors.initials: T
authors.lastname: Naito
authors.affiliation: Department of Internal Medicine.
authors.forename: Yuko
authors.initials: Y
authors.lastname: Kataoka
authors.affiliation: Department of Internal Medicine.
authors.forename: Osamu
authors.initials: O
authors.lastname: Hamada
authors.affiliation: Department of Internal Medicine.
authors.forename: Yo
authors.initials: Y
authors.lastname: Den
authors.affiliation: Department of Internal Medicine, St Luke's International Hospital, Tokyo, Japan.
authors.forename: Osamu
authors.initials: O
authors.lastname: Takahashi
authors.affiliation: Department of Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan.
authors.forename: Shigeki
authors.initials: S
authors.lastname: Fujitani
keywords: code status; do-not-resuscitate order (DNR)