Introduction     The basic steps in the DNR discussion for seriously ill hospitalized patients were described in Fast Fact #23, Fast Fact #365, and Fast Fact #366.  If you have followed those steps, what do you do if the patient or family/surrogate continues to want CPR and you think it is not in the patient’s best interest? The seemingly ‘unreasonable’ request for CPR typically stems from one of several themes.

1. Inaccurate information about CPR.   The public has an inflated perception of CPR success. While most people believe that CPR works 60-85% of the time, the actual survival to hospital discharge is more like 10-15% for all patients, and less than 5% for the elderly and those with serious illnesses.  This is a time to review/clarify the indications, contraindications, potential outcomes and morbidity of CPR.  Start by asking, “What do you know about CPR?”

2. Hopes, fears, and guilt.   Be aware that guilt (“I haven’t lived nearby to care for my dying mother”) and fear (“I am afraid to make a decision that could lead to my wife’s death”) are common motivating emotions for a persistent CPR request.  Some patients or families need to be given an explicit recommendation, or permission to stop all efforts to prolong life, to be told that that death is coming and that they no longer must continue “fighting”.  Whenever possible, try to identify the underlying emotions and offer empathic comments that open the door to further conversation. “This decision seems very hard for you.  I want to give you the best medical care possible; I know you still want CPR, can you tell me more about your decision?”

3. The moral burden of ‘choosing to die.’ Agreeing to a DNR order for some patients/families feels equivalent to them “choosing” to die, “giving up.” A patient may accept that they are likely to die, while also strongly feeling that it is their moral responsibility is to struggle against death and agreeing with a DNR order can feel like a betrayal of that obligation. Some patients see CPR as a “last chance” for continued life.  Probe with open-ended questions: “What do you expect to happen? What do you think would be done differently, after the resuscitation, that wasn’t being done before?” Many patients describe hope for a new treatment.  Use the opportunity to describe that you are doing everything in your power to prolong their life before a cardiopulmonary arrest – you wouldn’t be “saving something” to do after they had died.  If patients are not ready for a DNR order, don’t let it distract you from other important end-of-life care needs; emphasize the goals that you are trying to achieve; save a repeat discussion for a future time; good care, relationship building, and time will help resolve most conflicts.

4. Distrust of the medical care system.   Patients or families may give you a clue that there is a fundamental distrust of doctors or the medical system; this should be addressed openly. “What you said makes me wonder if you may not have full trust in the doctors and nurses to do what is best for you? Can you tell me about your concerns?”

5. Managing persistent requests for CPR.   Decide if you believe that CPR represents a futile medical treatment—that is, CPR cannot be expected to either restore cardiopulmonary function or to achieve the expressed goals of the patient (see Fast Fact #136).  Clinicians are not legally or ethically obligated to participate in a futile medical treatment, and some institutions have a policy that a clinician may enter a DNR order in the chart against patient wishes. Certainly, many institutions in the US do not have such policies. Aside from writing a DNR order without patient or family agreement, other options include:

• Transfer care to another clinician chosen by the patient/family (this should only be done rarely where there is an irreparable breach of trust between clinician and patient/family). 

• Plan to perform CPR at the time of death – but don’t end the discussion. Engage the patient about her or his wishes if they survive the resuscitation attempt.  Tell the patient that you need guidance because it is very likely that if she or he survives CPR, they will be on life support in the ICU, and they may not be able to make decisions for themselves; ask them (or the family) to help you determine guidelines for deciding whether to continue life-support measures.  If not already done, clarify if there is a legal surrogate decision-maker.

References 

1. Cantor MD, et al. Do-Not-Resuscitate orders and medical futility. Arch Int Med. 2003; 163:2689-2694.
2. Layson RT, OcConnell T. Must consent always be obtained for a Do-Not-Resuscitate order? Arch Int Med. 1996; 156:2617-2620.
3. Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on television. Miracles and misinformation. NEJM.1996; 334(24):1578-82.
4. Back A, Arnold R, & Tulsky, J. (2009). Mastering Communication with Seriously Ill Patients: Balancing Honesty with Empathy and Hope. Cambridge University Press. ISBN 978-0-521-70618-6.
5. Schenker Y, Crowley-Matoka M, Dohan D, Tiver GA, Arnold RM, White DB. I don’t want to be the one saying ‘we should just let him die’: intrapersonal tensions experienced by surrogate decision makers in the ICU. J Gen Intern Med. 2012 Dec;27(12):1657-65. doi: 10.1007/s11606-012-2129-y. Epub 2012 Jul 28. PMID: 23011253; PMCID: PMC3509291.

Version History:  This Fast Fact was originally edited by David E Weissman MD.  2nd Edition published July 2005; 3rd Edition May 2015;4th Edition April 2025.
Conflicts of Interest: None to report.