Although commonplace and widely accepted today, the development of the do-not-resuscitate order was, and remains, controversial on several fundamental issues at the intersection of medicine and ethics. As with artificial (mechanical) ventilation and artificial nutrition and hydration, the development of advanced cardiopulmonary resuscitation (CPR) techniques created decision points regarding treatment alternatives for both dying patients and their caretakers that had not previously been confronted.

Prior to 1960 there was little that physicians could do for a patient in the event of sudden cardiac arrest. In that year, surgeons at Johns Hopkins Medical Center reported a technique for closed-chest massage combined with "artificial respiration" and designed specifically for patients suffering anesthesia-induced cardiac arrest. This condition was especially conducive to closed-chest massage because it often occurred in otherwise healthy patients who needed only short-term circulatory support while the adverse effects of anesthesia were resolved. In the context for which it was designed—transient and easily reversible conditions in otherwise healthy individuals—the technique at first appeared miraculous for its effectiveness and simplicity. A 1960 article in the Journal of the American Medical Association stated: "Anyone, anywhere, can now initiate cardiac resuscitative procedures. All that is needed are two hands" (Kouwenhoven, Jude, and Knickerbocker, pp. 1064—1067).

Partly because of its simplicity, and partly because of uncertainty over who might benefit from the performance of CPR, it soon became the rule and not the exception that any hospitalized patient experiencing cardiac arrest underwent a trial of resuscitative efforts. These attempts often transiently restored physiologic stability, but too often also resulted in prolonged patient suffering. By the late 1960s, articles began appearing in the medical literature describing the agony that many terminally ill patients experienced from repeated resuscitations that only prolonged the dying process (see Symmers).

Soon a covert decision-making process evolved among clinicians regarding the resuscitation decision. When physicians and nurses responded to situations in which they believed that CPR would not be beneficial, they either refused to call a code blue or performed a less than full resuscitation attempt. New terms, such as slow code and Hollywood code, entered the vocabulary of the hospital culture as these partial or half-hearted resuscitation efforts became more pervasive.

Lacking an established mechanism for advanced decision making about resuscitation, some hospitals developed their own peculiar means of communicating who would not receive a full resuscitation attempt in the event of cardiopulmonary arrest. Decisions were concealed as purple dots on the medical record, written as cryptic initials in the patient's chart, or in some cases simply communicated as verbal orders passed on from shift to shift.

The absence of an open decision-making framework about resuscitation decisions was increasingly recognized as a significant problem in need of a solution. Unilateral decision making by clinicians in this context effectively circumvented the autonomy of the patient and prevented the full consideration of legitimate options by the involved parties prior to a crisis. From the patient's perspective, this covert decision making resulted in errors in both directions: some patients received a resuscitation attempt in circumstances where they did not desire it, while others did not receive a resuscitation attempt in circumstances where they would have desired it.

In 1976 the first hospital policies on orders not to resuscitate were published in the medical literature (see Rabkin). These policies mandated a formal process of advance planning with the patient or patient's surrogate on the decision of whether to attempt resuscitation, and also stipulated formal documentation of the rationale for this decision in the medical record. In 1974 the American Heart Association (AHA) became the first professional organization to propose that decisions not to resuscitate be formally documented in progress notes and communicated to the clinical staff. Moreover, the AHA position on DNR stated that "CPR is not indicated in certain situations, such as in cases of terminal irreversible illness where death is not unexpected" (American Heart Association).

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