Introduction
Some have advocated eliminating the term DNR due to its confusion; for example, does it apply only post arrest? The answer is yes. The problem is that a patient can be a "full code" pre-arrest and a "DNR" post arrest. What to do pre-arrest should be determined prior to the onset of a crisis and stating DNR is not helpful in guiding pre-arrest care.
In a quickly deteriorating patient we are frequently confronted with poor or incomplete identification of patient goals of care which is often magnified by the patients misunderstand of benefit vs risk, pain and suffering of various ACLS interventions.
Problem
Having the patient make these complex decisions abdicates the clinicians responsibility in medical decision making . One would not allow a patient to determine how technical aspects of complex intervention are preformed but only consent to the intervention knowing benefit and risk . A patient choosing a mired of ACLS interventions are no different as their understanding of the intervention benefit, risk, pain and suffering is often limited.. It is the physician responsibility to determine which ACLS interventions are likely to be of benefit with an acceptable risk, pain and suffering and then apply only those that are in keeping with patients goals of care.
Solution
Determining and ordering appropriate resuscitation status (DOARS) should be accomplished very early in a patients illness or admission to the hospital. Opening DOARS can assist in the above