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In 1992, one of us (Len Doyal) published a paper about the need for coherent guidelines to aid decisions on cardio-pulmonary resuscitation.1 By this time, much ink had been spilt on the importance of both informed consent and refusal of other forms of life sustaining treatment. However, a notable silence surrounded the variety of covert codes and signals entered into the notes of patients which indicated—without the patient’s knowledge—that they would not be resuscitated. A particularly stark example was a black star affixed to the cover of the clinical notes. Worse still was the revelation that all patients on some geriatric units were “not for resuscitation” for no other reason than their age.
All of this came to a head when the son of a competent elderly woman who was not terminally ill discovered a “do not resuscitate” (DNR) order in her notes and complained to the parliamentary ombudsman. Neither she nor her son knew anything about it and they were unable to question the order or its justification. The issue was further inflamed by similar stories in the press, a provocative television documentary, and protests by patients’ groups, especially those representing elderly people.2 The reasons for these expressions of public concern are obvious. Cardiopulmonary resuscitation (CPR) is a potentially life sustaining treatment. In no other clinical circumstance would it be acceptable to plan to deny such treatment to a competent patient without their knowledge. As a result, the chief medical officer asked hospitals to formulate clear policies on when DNR orders would be issued.
What was going on throughout the UK and elsewhere were moral judgements about whether or not the lives of some seriously ill patients—especially the elderly—were of such dismal quality that saving them was undesirable. Unlike other clinical circumstances where the non-provision or withdrawal …