Do-not-resuscitate: A Revolution Now 30 years old

"Because all the sick do not recover does not mean that there is no art of medicine."- Cicero, 143-06 BCE De Natura Deorum

“And thus it seems a conspiracy of silence has descended . . . We all pretend toward our neighbor that the possibility of his death could never happen.”- Albert Schweitzer

This month marks the 30 year anniversary of a fundamental shift in America's approach to end of life care.  Thirty years ago, it was impossible to issue a legal Do-Not-Resuscitate order. Then, on June 30, 1978, came a legal decision that remains the bedrock of a new legal, ethical and moral consensus that has guides medicine today.

 “In the matter of Shirtly Dinnerstein.” Dinnerstein, 380 NE2d, 134,135 (Mass App 1978) made clear that Do-not-resuscitate (DNR) orders can be issued without court intervention, because the decision to resuscitate or not resusciate “is a question peculiarly within the competence of the medical profession.” 

Before Dinnerstein, doctors believed that they had to go to court to stop extraordinary life support. Doctors felt a “technological imperative” to do “everything possible,” regardless of whether an intervention could work, and regardless of whether a patient wanted a futile intervention.

Two years previous to Dinnerstein, a New Jersey court in 1976 had ruled in the Karen Ann Quinlan case that all persons had the right to refuse treatment. But the Quinlan court did not make clear how this right could be implemented without court review on a case-by-case basis.

I was a first year medical student at University of Michigan in 1978, and remember the immense relief when Dinnerstein issued. The hospital attorney, Ed Goldman, and noted ethicists Carl Cohen, hailed the decision as common sense: decisions at the end of life were personal, and had to be made between doctor, patient and family. Courts did not need to involve themselves.

Father Richard McCormack, the theologian from the Quinlan case (and, by coincidence, a friend of my family), wrote in 1978 “The Quality of Life, The Sanctity of Life,”  reflecting a quote from Martin Luther King that “The quality, not the longevity, of one's life is what is important.”

Earlier, Pope Pius XII  condemned in 1952 "extraordinary means" to maintain life against the will of patients. All of the major religions remain in agreement. Doctors now work with chaplains and rabbis of all faiths to help patients make these decisions.

Dinnerstein became the basis of the President's commission on  Standards for cardiopulmonary resuscitation (CPR) and was adopted by the American Medical Association Report on Standards for Cardiopulmonary Resuscitation, declaring, "The purpose of cardiopulmonary resuscitation is the prevention of sudden, unexpected death. Cardiopulmonary resuscitation is not indicated in certain situations, such as in cases of terminal irreversible illness where death is not unexpected or where prolonged cardiac arrest dictates the futility of resuscitation efforts. Resuscitation in these circumstances may represent a positive violation of an individual's right to die with dignity." 

Most medical societies followed suit, and Dinnerstein became embedded into medical standards throughout the country, and in other countries. 

It is now realized that doctors should not prolong dying, but instead promote dignity. The physician must weigh the concepts of benefit and burden, and realize that such decisions are value judgments and moral decisions. The physician must always consider the quality of life of his/her patient, to which the patient can hopefully enlighten him/her. 

Over the past 30 years, the nation has witnessed debates over Terry Schiavo, and in popular culture in such movies as “Whose Life Is It Anyway?“ “Sea of Life,” and “Million Dollar Baby.” But no one seriously denies that a patient has the right to refuse treatment, and that futile or inhumane treatment should be discouraged. Margaret Edson's Pulitzer prize winning play “Wit” became the basis of new medical school initiatives to discuss the need for end of life dignity. Bill Moyers had famous series on this topic. 

We may take the need for the concept of dignity, and for the need for DNR orders almost for granted in 2008. Certainly, grey areas remain, and public discussion remains needed. But we need to remember that today's discussion, and today's law, remains grounded in the 1978 Dinnerstein discussion. 

Is this still a  "Brave New World?" In reality, questions of our mortality have always been with us, and are “only new to thee.” This year, in the wake of Schiavo, and in the turbine of other medical reforms, we need to continue the discussion that was begun 30 years ago, in the case of Dinnerstein.