title: Opening ethical doors.
abstract: In March 1988 an 88 year old woman was admitted to a hospital suffering from bronchopneumonia. During the evening of her first day of admission a 'do not resuscitate' (DNR) decision was taken and entered into her clinical notes. The case was investigated by the Health Service Commissioner following a complaint by the patient's son who purely by chance saw the words 'not for the 222s' (a DNR order) on his mother's case notes.