Improving do-not-resuscitate discussions: a framework for physicians.

Dr. Taylor is Associate Professor of Neurology, Dr. Gustin is Assistant Professor of Internal Medicine, and Dr. Wells-DiGregorio is Assistant Professor of Psychiatry at the Center for Palliative Care, The Ohio State University, Columbus, Ohio. H aving DNR (do-not-resuscitate) discussions with patients and their surrogates is a challenging task for most oncologists. To make such discussions more constructive, we provide a framework that stratifies patients into three general groups: (1) the basically healthy, (2) those with an advanced or chronic illness, and (3) the imminently dying. This framework permits physicians to tailor their discussions to the specific needs of each patient or surrogate and to make recommendations when appropriate. In discussing DNR orders, physicians struggle with two re lated challenges. First is how should they frame the discussion so that patients and surrogates understand the medical situation, including the benefits and burdens of their decisions? Second is to what extent is it appropriate to make recommendations? The lack of “best practices” for communicating uncertainty further complicates DNR discussions.1–3 Although DNR orders should usually be discussed in the context of a broader conversation about the goals of care and advance care planning, they are sufficiently unique that it is instructive to consider them as a distinct issue.