Life Matters
DaNgeR--DNR!!!
by Earl E. Appleby, Jr.
While attempts to resuscitate people with cardiac or respiratory arrest began almost as early as recorded
history, cardiopulmonary resuscitation (CPR) by closed chest cardiac massage was first described in the Journal of the
American Medical Association (JAMA) in 1960. In 1966, the National Academy of Sciences recommended that all health care
professionals be taught this life-saving procedure. Soon laymen were being trained as well.
"Because the alternative for a patient in cardiac arrest is death, ensuring access to CPR for all who need it
is vital," notes Congress's Office of Technology Assessment (OTA).
Yet in 1976, two Boston hospitals, Massachusetts General and Beth Israel, disclosed policies denying life-saving
treatment, including CPR, to targeted patients. The New England Journal of Medicine described this surrender to death
as an "open secret" among the medical brotherhood.
Mass General patients were assigned to "therapeutic" categories. Physicians could deny less favored patients CPR without
advising the patient or family. Family consultation was only required for "acts of commission" such as causing death by disconnecting
a life-saving ventilator. Letting the patient know he was going to be killed was purely optional.
The Mass General policy followed a 1974 recommendation by the National Conference on Standards for Cardiopulmonary Resuscitation
and Emergency Cardiac Care advising physicians to note the "inappropriateness" of CPR in the patient's medical chart and to
issue a written order to "do not resuscitate" (DNR) "for the benefit of nurses and other personnel who may be called upon
to initiate or participate in cardiopulmonary resuscitation."
A 1981 New York grand jury investigation revealed a death-selection system in a Queens hospital in which purple dots were
affixed to the charts of patients who were not to be resuscitated. The dot was removed after the victim's demise.
The physician who designed dots-for-death defended them as "nothing more than suggestions, if you will, to the nurse who
is perfectly at liberty to call the code if she desires." The reality, however, is that ethical nurses have been fired for
opposing such covert DNR's, another reason why CURE supports a conscience clause for health care professionals.
American physicians are not alone in practicing stealth DNR. The Ontario Medical Review cites the following subterfuges
employed by Canadian doctors to end their patients' lives: "verbal suggestions (passed from shift to shift by word of mouth),
orders recorded in pencil on the nursing card index, to be surreptitiously erased after the event, circumlocutions in the
progress notes ('requires compassionate care only'), cabalistic symbols on patient records and the unforgivable 'slow code'
(start CPR, but only after we have a coffee)."
A deadly cousin of the slow code (a.k.a. "the light blue code") is the "show code," described by the New York
State Task Force on Life and Law as token activity "conducted for the benefit of the patient's family which makes it appear
as if resuscitation is being attempted." "The slow code, show code, and dot system," the Task Force concludes, "are all means
of achieving the results of a DNR order [i.e., "no code"] without risking the legal liability associated with the issuance
of an order."
A study reported in JAMA reviewed the records of 521 patients who died after cardiopulmonary arrest at
Beth Israel hospital from 1983 through 1984. Seventy-five percent of these patients were designated DNR, but only 22 percent
of these were involved in the decision. In 14 percent of the cases neither the patient nor the family was consulted.
"The physician has a responsibility to assure that his hopelessly ill patient dies with dignity," declares the Annals
of Internal Medicine, "If a physician decides that the disease process or other medical condition that the patient has
would not be positively affected by the initiation of resuscitative efforts in other words, if resuscitative efforts would
only prolong the dying process then a decision to write a do-not-resuscitate order is ethically appropriate."
"Death with dignity" and "prolonging the dying process" are euphemisms for euthanasia, which is itself a euphemism since
it is anything but "a good death." Resuscitation is not designed to cure cancer or spina bifida but to restore a beating heart
in a breathing, living human being, i.e., to save a life.
Euthanasia can kill you from fertilization to death. The following "medical conditions" seeking to justify pediatric DNR's
were cited in the American Journal of Law and Medicine: myelomeningocele, Trisomy 21 or Down's syndrome, Trisomy 13,
anencephaly, encephalomeningocele, perinatal trauma, etc.
"Some elderly and other people who might benefit from CPR do not receive it," the OTA concluded. "Elderly people
may be less likely then younger people to receive CPR because of a widespread perception that elderly people are less likely
to benefit from it." ("Benefit" almost invariably is used as a code word for "quality of life" in today's medical and theological
jargon.)
And should the family, if notified, object? "A decision to withhold supportive therapy, while ethically sound, may not
be acceptable to some families for religious or other reasons. ['Thou shalt not kill'?] Their wishes must be considered but
not necessarily followed. The physician must be the final arbiter in decisions related to a patient."
Noting that unilateral decisions to deprive patients of CPR against their wishes and those of their family increase the
risk of litigation, the Archives of Internal Medicine observes, "To avoid these problems, some physicians may give
a verbal order not to resuscitate the patient but fail to document the order in the patient's medical record."
Of course, unscrupulous physicians can camouflage their anti-life philosophy as medical prognosis. A 1981 statement
by the California Department of Health affirmed that no-code patients "are not appropriate to be in acute care hospitals."
Hospitalized patients with DNR orders are routinely denied other medical care.
The previously cited JAMA study found that in one year in one hospital 110 no-coded patients were deprived of other
care. "This change in care included a wide spectrum of diagnostic and therapeutic interventions, ranging from drawing blood
to withholding potentially life-saving dialysis or surgery."
A study in one ICU found that treatment such as blood transfusions, dialysis, and mechanical ventilation were withheld
from 68 percent and withdrawn from 40 percent of patients with DNR orders.
The JAMA study found that "No medical care was withdrawn or withheld from the patients who were resuscitated after
cardiac arrest, unless they were later designated DNR."
HLI Reports, October 1990
