Does a Living Will Equal a DNR? Are Living Wills Compromising Patient Safety?


      Living wills are thought to protect the medical decision-making capacity of patients. Presented are three case scenarios of patients with living wills presenting to health care facilities for treatment, and their hospital courses. Living wills have never been thought to compromise patient care or safety, but their use has not been adequately studied with respect to risks, benefits, or consequences. This case series will define a scenario as well as how that scenario was affected by the presence of a living will. In addition, existing data regarding the care provided to patients with a code status designation of DNR (do not resuscitate) are reviewed.


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        • U.S. Census Bureau
        2004 Population Estimates, Census 2000, 1990 Census.
        2005 (Available at. Accessed March)
        • Degenholz H.B.
        • Rhee Y.
        • Arnold R.M.
        The relationship between living will and dying in place.
        Ann Intern Med. 2004; 141: 113-117
      1. Pa. C.S. Title 20; Chapter 54; Advanced Directives for Health Care, Sections 5401–16.

        • Bartholome W.G.
        “Do not resuscitate” orders: accepting responsibility.
        Arch Intern Med. 1988; 148: 2345-2346
        • Emergency Cardiac Care Committee and Subcommittees
        • American Heart Association
        Guidelines for cardiopulmonary resuscitation and Emergency Cardiac Care, VIII: ethical considerations in resuscitation.
        JAMA. 1992; 268: 2282-2288
        • Presidents Commission for the study of Ethical Problems in Medicine and Biomedical Research
        Deciding to forego life-sustaining treatment: ethical, medical and legal issues in treatment decisions.
        in: US Government Printing Office, Washington, DC1983: 231-255
        • Miles S.H.
        • Crawford R.
        • Shultz A.L.
        The do-not-resuscitate order in a teaching hospital.
        Ann Intern Med. 1982; 96: 660-664
      2. Standards for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC): medico legal considerations and recommendations.
        JAMA. 1986; 255: 2979-2984
        • Henneman E.A.
        • Baird B.
        • Bellamy P.E.
        • Faber L.L.
        • Oye R.K.
        Effect of do-not-resuscitate orders on the nursing care of critically ill patients.
        Am J Crit Care. 1994; 3: 467-472
        • Sherman D.A.
        • Branum K.
        Critical care nurses’ perceptions of appropriate care of the patient with orders not to resuscitate.
        Heart Lung. 1995; 24: 321-329
        • Youngner S.J.
        Do-not-resuscitate orders: no longer a secret but still a problem.
        Hastings Cent Rep. 1987; 17: 24-33
        • Uhlmann R.F.
        • Cassel C.K.
        • McDonald W.J.
        Some treatment-withholding implications of no code orders in academic hospital.
        Crit Care Med. 1984; 12: 879-881
        • La Puma J.
        • Silverstein M.D.
        • Stocking C.B.
        • Roland D.
        • Seigler M.
        Life-sustaining treatment.
        Arch Intern Med. 1988; 148: 2193-2198
        • Bedell S.E.
        • Pelle D.
        • Maher Pl.
        • Cleary P.D.
        Do-not-resuscitate orders for critically ill patients in the hospital.
        JAMA. 1986; 256: 233-237
        • Fragerlin A.
        • Schneider C.E.
        Enough: the failure of the living will.
        Hastings Cent Rep. 2004; 34: 30-42
        • Goodman M.D.
        • Tarnoff M.
        • Slotman G.J.
        Effect of advanced directives on the management of elderly critically ill patients.
        Crit Care Med. 1998; 26: 701-704
        • Beach M.C.
        • Morrison R.S.
        The effect of do-not-resuscitate orders on physician decision-making.
        J Am Geriatr Soc. 2002; 50: 2057-2061
        • Bedell S.E.
        • Delbanco T.L.
        Choices about cardiopulmonary resuscitation in the hospital.
        N Engl J Med. 1984; 310: 1089-1093
        • Lewandowski W.
        • Daly B.
        • Mclish D.K.
        • Juknialis B.W.
        • Younger S.J.
        Treatment and care of “do not resuscitate” patients in a medical intensive care unit.
        Heart Lung. 1985; 14: 175-181
        • Thibault-Prevost J.
        • Jensen L.A.
        • Hodgins M.
        Critical nurses’ perception of DNR status.
        J Nurs Scholarsh. 2000; : 259-265
        • Hewitt W.J.
        • Marco C.A.
        DNR. does it mean “do not treat”?.
        ACEP News. 2004; (June): 3
        • Shelly S.I.
        • Zahorchak R.M.
        • Gambril C.D.S.
        Aggressiveness of nursing care for older patients and those with do-not-resuscitate orders.
        Nurs Res. 1987; 36: 157-162
        • Tulsky J.A.
        • Fisher G.S.
        • Rose M.R.
        • Arnold R.M.
        Opening the black box: how do physicians communicate about advanced directives?.
        Ann Intern Med. 1998; 129: 441-449
        • Larson D.G.
        • Tobin D.R.
        End-of-life conversations evolving practice and theory.
        JAMA. 2000; 284: 1573-1578
        • Morrison M.F.
        Obstacles to doctor-patient communication at the end of life.
        in: Steinberg M.D. Youngner S.J. End-of-life decisions: a psychosocial perspective. American Psychiatric Press, Washington, DC1998: 109-136