End-of-life care in the intensive care has become a shared decision-making process in the United States and such an approach is considered more satisfactory than decisions based on physician’s authority alone. When asked in surveys, most families appreciate a physician’s openness and directness. Families would want to know what to expect and what are the limitations of aggressive interventions. In patients with very poor prognosis it is important to review the chances of a successful resuscitation effort.

Where did a do-not-resuscitate (DNR) order originate? In 1974, the American Medical Association stated in an article devoted to standards that “cardiorespiratory resuscitation was not indicated in certain situations.” Other opinions were voiced, including the 1983 President’s Commission on “deciding to forego life sustaining support.” This led to a major change in practice, in which doctors now had the opportunity to discuss any intervention before the event. Most major medical organizations supported the view that do-not-resuscitate orders can be discussed as part of care. How to communicate this to family members or even whether to discuss the actual procedure of cardiopulmonary resuscitation has remained an underdeveloped field of medicine, and training of this part of end-of-life care in residencies is generally not common place.

What do the data say about the success of cardiopulmonary resuscitation in the intensive care unit? In most large series of resuscitated critically ill patients with diverse diagnoses not more than 15% survive to discharge. Advanced age and comorbidity (i.e., cancer) reduce the odds even more. Patients with acute deteriorating neurologic disease complicated by cardiac arrest and cardiopulmonary resuscitation have a very dismal outcome, if they survive at all. Some empirical guidelines in patients with acute neurologic disease are clearly warranted, but none exist. In an earlier statement there appeared to be consensus among stroke physicians that DNR orders are appropriate if 2 of the 3 following criteria are met: 1) severe deficit, persistent or deteriorating and with impaired consciousness; 2) life-threatening brain damage with brainstem compression involving multiple brainstem levels; 3) significant comorbidity, including pneumonia, pulmonary emboli, sepsis, recent myocardial infarction, and life-threatening arrhythmias. Criteria for other critical neurologic conditions have not been developed, but most physicians attending in the NICU would discuss DNR orders—if not already made clear by family members—or an advance directive, if there is permanent and severe primary brain and brainstem injury.

A DNR order clearly specifies no cardiopulmonary resuscitation (no chest compressions, no pharmacologic or electrical cardioversion). Do not intubate orders (no endotracheal intubation or invasive mechanical ventilation) typically accompany the DNR order, but exceptions occur. Orders limiting aggressive care may also prohibit use of noninvasive (BiPAP) mechanical ventilation, intravenous drugs or infusions for cardiac arrhythmias with preserved circulation, cardiac pacemakers, or chest tubes, among other supportive devices indicative of aggressive care. However, it is important to keep in mind that a DNR order per se should not affect the level of care provided to the patient except obviously in the case of a cardiac arrest. Other restrictions of medical treatment or de-escalation of care should be specified separately from the DNR order.

These distinctions are crucial to avoid unintended problems with a DNR order. Some studies have found that DNR orders may negatively influence triage to the ICU. Some patients may feel that DNR order may impact aggressiveness of care. Multiple studies have found that certain cultures will see a DNR order as equivalent to withholding treatment. It should not. In some situations DNR could be the first step toward de-escalation of care. However, in itself DNR merely defines the limits of care.

In the United States surrogates are able to make decisions, and they could be guided by advance directives. A living will directs proxy to withhold or withdraw treatment at the end of life. A living will is usually formulated in broad terms (often containing a sentence such as, “if I have terminal disease I do not want to be resuscitated”), and obviously rarely includes specifics on acute neurologic disease. Decision makers for the patients therefore will have to interpret such a will. Nonetheless the mere fact a living will exists indicates that the patient has anticipated that a difficult medical situation may occur in the future. It expresses a wish by the patient to assist family members in making such decisions.

So what should we do in this situation? Providing factual information is the first course of action, and this requires a formal family conference (Table 29.1). Sitting down and having a conversation in a separate room is far more appropriate than a cursory discussion at the bedside. Physicians may need to use visual aids (showing the large destructive hemorrhage), establish trust under stressful circumstances, and may need multiple conversations which should include having the family summarize the assessment of the situation. Physician should respect cultural and religious beliefs, but these may be an impediment to rational medical care. In many families considerable time may be needed to grasp the finality of the condition.

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