Exploring the ethical complexities of do-not-attempt-resuscitation orders using the approach of advance care planning

I am writing to provide feedback on the study by Tsuji and colleagues (2023)¹ that investigated the association between rapid response system activation and subsequent do-not-attempt-resuscitation (DNAR) orders. While this study enriches our understanding, it also encourages further consideration of the advance care planning (ACP) approach within the evolving decision-making framework.²

The decision to order a DNAR involves complex ethical issues that extend beyond the postcardiac arrest situation.³ Not only do DNAR orders affect prearrest medical interventions, but the timing of these orders also requires careful consideration. There is a balance to be struck: while early orders may deprive patients of potential resuscitative benefits, delaying them may result in missed opportunities. In addition, the scope of the DNAR order itself raises an important question: Does it apply only to cases of underlying disease progression, or does it extend to unexpected cardiac arrests resulting from accidents or abuse? These complexities are exacerbated when elderly patients transition between health care facilities, creating ambiguity in the interpretation of DNAR orders.

This is where the ACP approach needs to be applied. The lack of comprehensive guidelines for DNAR orders contributes to uncertainty. Balancing patient preferences with the potential benefits of resuscitation presents a complex ethical dilemma, and the ACP approach offers a potential solution to such problems. It is a decision-making process that involves a broader perspective than just the DNAR order itself. Through empathic and supportive communication, the ACP approach respects patients’ values and lifestyles, while fostering trust between health care professionals and patients. The ACP approach ensures informed decision making that addresses patients’ concerns about end-of-life care.

The focus will be on incorporating the ACP approach beyond the DNAR instruction itself to the broader decision-making framework.^{4, 5} This integration is not limited to postcardiac arrest interventions, but will also include decisions made before such critical events. In this context, it is essential to recognize that all patients are vulnerable. Therefore, health care professionals should genuinely accept the suffering that results from this vulnerability. The willingness of health care professionals to engage in difficult yet thoughtful decision-making discussions with patients is of profound importance. This collaborative and compassionate decision making would contribute to patients leading more fulfilling lives.

In conclusion, overcoming the complex ethical issues associated with DNAR orders requires a collaborative effort to expand the ACP approach within a decision-making framework. Reducing the ambiguity surrounding DNAR orders and establishing a resilient decision-making system are both critical in an ever-evolving medical landscape. The study by Tsuji and colleagues is an important stepping stone for further exploration of the dynamic interaction between DNAR decisions, the ACP approach, and diligent efforts to address ethical issues.

The authors declare no conflicts of interest.

This manuscrpit was conducted in accordance with the Declaration of Helsinki and the Ethical Policies of Clinical Research and Clinical Ethics of Sasebo City General Hospital.