Is it always wrong to perform futile CPR?

Tell Parents the Truth, but Tell It Slant

This article draws on fiction, poetry, and memoir to suggest that for many people, tragic choices are best dealt with not through explicit conversations that directly confront difficult truths but, instead, through indirect and ambiguous conversations that only suggest what is most important. Telling the truth slant is not easier than telling it directly. It requires more imagination and perhaps more sensitivity to the parents' nonverbal cues. The underlying moral principles are the same in the 2 approaches. The values and preferences of the patient and the family should be given highest priority. But to respect those values and honor those preferences, doctors need to listen carefully to understand what parents are saying, what they are not saying, what they mean, and what they need. Sometimes they may be saying that there are things that they prefer not to discuss or decisions that would prefer not to affirm.

Unilateral pediatric "do not attempt resuscitation" orders: the pros, the cons, and a proposed approach

A unilateral do not attempt resuscitation (DNAR) order is written by a physician without permission or assent from the patient or the patient's surrogate decision-maker. Potential justifications for the use of DNAR orders in pediatrics include the belief that attempted resuscitation offers no benefit to the patient or that the burdens would far outweigh the potential benefits. Another consideration is the patient's right to mercy, not to be made to undergo potentially painful interventions very unlikely to benefit the patient, and the physician's parallel obligation not to perform such interventions. Unilateral DNAR orders might be motivated in part by the moral distress caregivers sometimes experience when feeling forced by parents to participate in interventions that they believe are useless or cruel. Furthermore, some physicians believe that making these decisions without parental approval could spare parents needless additional emotional pain or a sense of guilt from making such a decision, particularly when imminent death is unavoidable. There are, however, several risks inherent in unilateral DNAR orders, such as overestimating one's ability to prognosticate or giving undue weight to the physician's values over those of parents, particularly with regard to predicted disability and quality of life. The law on the question of unilateral DNAR varies among states, and readers are encouraged to learn the law where they practice. Arguments in favor of, and opposed to, the use of unilateral DNAR orders are presented. In some settings, particularly when death is imminent regardless of whether resuscitation is attempted, unilateral DNAR orders should be viewed as an ethically permissible approach.