Practical guidelines for do-not-resuscitate orders.

Do-not-resuscitate orders are widely used, but discussions about their use too often take place late in the patient's illness, after the patient is no longer able to participate in the decision. Most patients have discussed resuscitation issues with their family and would like to have a similar discussion with their physician, but only 10 percent of patients have done so. Although few states have laws addressing the use of do-not-resuscitate orders, they are widely held to be legal based on existing legal precedent. To assist patients or their designated surrogate decision-makers, physicians should supply appropriate prognostic information: one-half of all patients survive resuscitation initially, one-third survive for 24 hours and one-eighth survive to leave the hospital. Certain medical conditions, such as metastatic cancer, impaired renal function, sepsis and dependent functional status are associated with a poor outcome. If conflict occurs, properly facilitated family meetings, repeated discussions and ethics committee consultations can be useful. Legal action should remain a last resort.