[Decision-making relating to cardio-pulmonary resuscitation attempts].

A 78-year-old previously healthy and very active patient is urgently admitted to a hospital on a late Saturday evening for his first attack of angina pectoris. Referring to a previously drafted living will (kept at home) he refuses his consent for transfer to the intensive care unit (ICU). A DNAR (Do Not Attempt Resuscitation) order is entered in the patient's chart. After his condition has stabilized in the emergency room the patient is transferred to an ordinary ward. By the next morning the patient has been admitted to the ICU after successful cardiopulmonary resuscitation following cardiac arrest, which had occurred on the ward while the patient was left unobserved for a moment. In fact, he is intubated and artificially ventilated. He is in a critical state and his neurological outcome is uncertain. A number of hotly debated issues arise: Was it wrong to resuscitate the patient? Focusing on the DNAR order, how should the decision-making process look like, and what about the further management of the case? Could any help be expected from the new guidelines on DNAR decision-making recently published by the Swiss Academy of Medical Sciences (www.samw.ch)? The case presented illustrates the ethical complexity of modern clinical practice in general. It is true that the article raises a lot of unanswered questions, but at the same time it is looking ahead and gives insights into what a structured ethical decision-making process looks like. The article is meant to stimulate involvement with practical clinical ethics; which is why it has been placed at the beginning of the present issue of Therapeutische Umschau.