Redefining the emergency physician's role in do-not-resuscitate decision-making.

In summary, Wrenn and Brody's [14] study raises important questions about the appropriate role of emergency physicians in discussing DNR decisions in the emergency setting. Their approach to DNR orders expands, appropriately we believe, the traditional role of emergency physicians. We suggest that it is desirable for emergency physicians to give patients and family members the option of DNR status when there is a significant likelihood that the patient will experience cardiopulmonary arrest before the admitting physician can address the DNR issue and the patient is profoundly debilitated or terminally ill. In addition, emergency physicians have a heightened obligation to promptly address DNR status when appropriate decisions about resuscitation have been reached previously, as in the following cases: (1) when a clearly valid portable prehospital DNR order is in effect; (2) when the patient's primary physician clearly indicates to the emergency physician that the patient is DNR; (3) when an incompetent patient has an advance directive that explicitly precludes CPR and unquestionably applies to the current situation; (4) when a clearly competent, informed patient requests that a DNR order be entered. Finally, we advise emergency physicians against using the principle of futility as sole justification for DNR orders except in situations in which cardiopulmonary arrest is expected, and outcome data suggest that survival is virtually unprecedented.