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Withdrawing and withholding treatment are equally justifiable, ethically and legally. Treatments should not be withheld because of the mistaken fear that if they are started, they cannot be withdrawn.

This practice would deny patients potentially beneficial therapies. Instead, a time–limited trial of therapy could be used to clarify the patient’s prognosis. At the end of the trial, a conference to review and revise the treatment plan should be held. Some health care workers or family members may be reluctant to withdraw treatments even when they believe that the patient would not have wanted them continued. The physician should prevent or resolve these situations by addressing with patient’s family feelings of guilt, fears and concerns before the life support system is withdrawn.

Do–Not–Resuscitate Orders
Intervention in the case of a cardiopulmonary arrest is inappropriate for some patients, particularly those with terminal irreversible illness whose death is expected and imminent. Because the onset of cardiopulmonary arrest does not permit deliberative decision making, decisions about resuscitation must be made in advance.

Physicians should especially encourage patients who face serious illness or who are in advanced old age or their surrogates, to discuss resuscitation. Although a do–not–resuscitate order applies only to cardiopulmonary arrest, discussions about this issue often reflect a revision of the larger goals and means of the care plan. The entire health care team must be carefully apprised of the nature of these changes. Do–not–resuscitate orders or requests for no cardiopulmonary resuscitation should specify care strategies and must be written in the medical record along with notes and orders that describe all other changes in the treatment goals or plans.

It is essential that patients or surrogates understand that a do–not–resuscitate order does not mean that the patient will be ineligible for other life–prolonging measures, both therapeutic and palliative. However, the appropriateness of a do–not–resuscitate order during and immediately after any procedure needs to be individually negotiated. It is unethical for physicians or nurses to perform half–hearted resuscitation efforts (“slow codes”).

Sometimes a patient or surrogate insists on a resuscitation effort, even when they are informed that it will almost certainly fail. A family’s religious or other beliefs or need for closure under such circumstances deserve careful attention. Although the physician need not provide an effort at resuscitation that cannot conceivably restore circulation and breathing, the physician should help the family to understand and accept this position. It is more controversial whether physicians may unilaterally write a do–not–resuscitate order when the patient may survive for a very brief time in the hospital.

Empathy and thoughtful exploration of options for care with patients or surrogate decision makers should make such impasses rare. Full discussion about the issue should include the indications for and outcomes of cardiopulmonary resuscitation, the physical impact on the patient, implications for caregivers, the do–not–resuscitate order, the legal aspects of such orders and the physician’s role as patient advocate.

Physicians who write a unilateral do–not–resuscitate order must inform the patient or surrogate.