Exploring “Do Not Resuscitate” (DNR) Decisions with Hope

This article was published exclusively online in the Christian Research Journal, volume 48, number 02 (2025).

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My father lay in his bed in ICU, having been mostly unconscious for days. Despite the best hopes of our family and his brief surge of consciousness, he displayed unmistakable signs of progression toward natural death. The question the doctor put to me, as my father’s medical surrogate, was: if something happens — if his heart stops — do we want to attempt resuscitation? Would it be his wish or my family’s wish for my father to be subjected to CPR or the use of a defibrillator, or is it time to place a Do Not Resuscitate order. I understood the doctor was asking if I was prepared to accept my father was dying.

A Do Not Resuscitate order (DNR) is a medical directive stating that in the event of a cardiac event which stops the heart or if breathing stops, medical professionals will take no measures to resuscitate the patient, whether by chest compressions through Cardiopulmonary Resuscitation (CPR), intubation (insertion of a breathing tube), or defibrillator (an electric shock to reset the cardiac rhythm). The patient or the patient’s surrogate can decide to activate a DNR, or in some cases it can be activated under the strong advisement of medical professionals and ethics committees once the decision has been reached that the negative consequences of attempts to resuscitate outweigh the probability of successful recovery. The AMA Code of Ethics states that once a DNR is in place, doctors may not intervene, even in situations where resuscitation would otherwise be medically appropriate.¹ They must respect the autonomy of the patient.

As straightforward as it may sound, complications arise. There are ethical questions to be considered as to when it is appropriate to enact a DNR, determining who takes responsibility to ensure the DNR is respected, establishing lines of recourse patients might have when medical professionals ignore DNRs, and preparing doctors and nurses to talk to patients about considering a DNR without sounding as if they are giving up on providing medical care. Research in 1999 indicated doctors may ignore the directive if they differentiate between natural cardiac and pulmonary events and those occurring during medical procedures,² while Emergency Medical Technicians (EMTs) following their professional mandate may aggressively pursue resuscitation before discovering the patient did not want treatment.³ This creates an odd nexus where the dictates of medical professionals to preserve life can cross the line into the legal territory of battery, the category of laws which protect DNR requests.⁴

One issue in addressing DNRs stems from a misperception built through fictional story lines that CPR enjoys a much higher success rate than it actually does.⁵ The problem is so pervasive that some advocate for changing the terminology to Do Not Attempt Resuscitation (DNAR) or Allow Natural Death (AND), which would transition away from language communicating a false idea that resuscitation is a choice rather than an act of medical desperation intended to give a person suffering cardiac arrest or pulmonary distress some small chance of survival.⁶

A balance must be struck by all parties involved, grounded in the value and dignity of human life. Paternalistic medical practices — where doctors treat patients like children and dictate treatment options — and, conversely, service-provider models — where patients treat doctors like concierge providers expected to fulfill their every request — both fail to recognize the importance of a mutually respectful relationship. Such a relationship honors medical professionals who serve their communities with purpose and integrity as a greater calling, and patients who trust their doctors and rely on their expertise to support their health and flourishing.

Christians should neither fear death nor rush to it. Our hope in an everlasting existence in union with God in Christ impacts every aspect of our relationship with life and death. Paul wrestles with this in Philippians 1:21–26, claiming he sees the act of living as enduring in Christ, and death as the completion of his labors. Christians embrace all the challenges of life in an effort to reflect the grace and mercy of our Lord into the lives of the people He commanded us to love as we love ourselves, but we can pass into death with the peace and confidence of a people hoping to hear Jesus welcome us home. A DNR, properly understood and executed, can help clarify for all parties involved how we wish to transition once our natural death approaches and our service this side of heaven is complete.

DNR vs Hastening Death

Pope John Paul II in his masterful encyclical letter Evangelium Vitae wrote about our duties to God regarding our medical treatment as we progress toward natural death. He builds on the general Catholic teaching that a person has “a moral obligation to use ordinary or proportionate means of preserving his or her life.”⁷ Pope John Paul II makes a clear moral distinction between euthanasia, the intentional seeking of death as a means of alleviating pain and suffering, and the forgoing of what he deems excessive medical treatments, “either because they are by now disproportionate to any expected results or because they impose an excessive burden on the patient and his family.”⁸ This refusal of further medical treatment is simply the recognition that our natural death is imminent and the attempts to prolong our life would exact a heavy and unnecessary toll of injury and resources. His articulation is helpful in framing the ideas in play.

A DNR lets individuals choose to set medical directives clarifying their wishes in the event they are incapacitated and incapable of expressing them in an emergency. The denial of extreme intervention does not indicate a desire to die, but an acceptance that death is the natural end. We are not morally required to live the maximal length of time medical science can deliver regardless of the negative impact interventions may have on our bodies. Resuscitation attempts make sense with patients suffering isolated incidents of cardiac or pulmonary distress. Older patients living with multiple pathologies contributing to a weakened state have legitimate reasons to consider whether a DNR is a good option for them. As Dr. Holland Kaplan of the Baylor College of Medicine wrote: “CPR does nothing to improve a person’s underlying medical conditions. My patient with severe anemia, heart failure, and metastatic cancer, had he been resuscitated, would still have had severe anemia, heart failure, and metastatic cancer. In addition to those issues, he would have a new host of problems from the CPR and resuscitation he had just endured.”⁹ 

Kaplan worries our culture prioritizes making heroic efforts to extend life. It is beneficial to rethink our commitments to extending life, what it means for how we die, and why neither patients nor medical professionals appear comfortable conversationally exploring the option of a DNR. Perhaps an exaggerated idea of the efficacy of CPR plays some role.

The Reality of CPR

The image is ubiquitous in medical dramas: a patient in distress, our hero leaning across the chest — either as the individual lies on the ground or, even more dramatically, astride the person on a hospital gurney — performing chest compressions, willing the patient back to life. Another young doctor slides in and intubates the patient to get air in the lungs. Sometimes, as the sound of the heart flatlining fills the room in the familiar high-pitched buzz, they break out the paddles and shock the patient back to life. Suddenly, the buzz turns into a beep. The medical team backs away, and the patient is slowly, groggily returned to health. This familiar scene is almost entirely fictional, a fiction leading many people to overestimate the ability to resuscitate a patient in cardiac or pulmonary distress. It is true CPR works as a bridge to real medical intervention, just not to the extent people have been led to believe in films and television.¹⁰

Lay people appear to overestimate how often CPR works.¹¹ The reality is far more complicated. The exact statistics are a bit difficult to attain, but a person receiving CPR outside of the hospital has somewhere around a 10–14 percent chance of making it to the hospital. Those percentages drop much lower as the age of the patient gets higher, and become frighteningly low with co-morbidities.¹² Should they survive, they will almost certainly suffer from broken ribs, a broken sternum, and possibly lacerated internal organs. Depending on the lag time between the start of the event and stabilization, they may also suffer irreversible cognitive impairment from lack of oxygen to the brain. The odds of a positive outcome, meaning they survive and eventually check out of the hospital, greatly improve if the cardiac or pulmonary event happens in the hospital surrounded by medical professionals, but there still may be broken ribs, cracked sternum, lacerated organs, and possible cognitive impairment. Defibrillators are an important tool, but they do not restart a stopped heart. They help a heart in the midst of cardiac arrest to recapture a healthy rhythm. Their quick use saves lives, but they cannot bring people back from the dead.

In 2012, Harvard Medical School shared an article indicating that when cancer patients visually understood what CPR is, how often it fails to extend life, and the likely physical repercussions, they were more likely to choose a DNR.¹³ Resuscitation is not an automatic choice. It is a last-ditch effort to help a fellow human being survive long enough to receive genuine medical assistance. And, it is worth repeating, resuscitation attempts have a high failure rate and if performed correctly are almost certain to be accompanied by undesired injuries. Thus, as explained above, many professionals have abandoned the use of the term DNR in favor of DNAR and AND, believing the adjustment of terms brings greater clarity to the conversation. By adding the A — Do Not Attempt Resuscitation — or changing the term altogether to Allow Natural Death, advocates for DNRs believe they can produce more open and honest assessment and informed consent.

The trauma of performing CPR is real and felt by medical professionals, leading some in the past to persistent nightmares and walking away from the field.¹⁴ Kaplan shares a personal story about how she would have preferred to hold one patient’s hand as he died rather than feel compelled to make his last moments miserable in a futile effort to force him to live a little longer. Knowledge of the high failure rate and the physical costs of CPR lead some doctors to refuse extreme measures to prolong their own lives.¹⁵ If medical professionals tend to hold a less optimistic view on the efficacy of CPR, then why perform it so often, even at times against the direct wishes of a patient with a clear DNR?

DNR, CPR, and Medical Professionals

An August 2024 New York Times article entitled “Doctors Saved Her Life. She Didn’t Want Them To” centers around Marie Cooper, an elderly woman with strong religious convictions and clear medical directives which doctors ignored after a routine check-up on her stomach cancer caused a pulmonary event.¹⁶ Though her directives absolutely forbid the insertion of a breathing tube, the staff sedated and intubated her. She lived, but the experience left her weakened, psychologically scarred, and incapable of taking care of her basic needs. Hers is one of multiple stories about medical professionals resuscitating patients with DNRs. How does this happen?

Kaplan suggests a view is fostered in the medical community that every life must end with heroic measures being applied.¹⁷ Other doctors appear to make a distinction between cardiac and pulmonary events that occur naturally and those which occur as a direct result of treatment, as in the case of Ms. Cooper.¹⁸ This distinction may be driven by a fear of legal action, especially if doctors are perceived as being indifferent toward a patient’s survival or if the adverse event is deemed the result of a medical error. Less charitable is the suggestion that a pay-per-service system encourages doctors to perform billable services to make more money or that doctors are more concerned with how a patient dying under their care will impact their publicly accessible statistics on care versus the wishes of their patient.¹⁹ In some cases, those treating patients with DNRs simply could not know before care was offered due to the unpredictability of emergency situations.²⁰

According to the U.S. Supreme Court decision Cruzan v. Director, Missouri Department of Health (1990), medical professionals need to be concerned with violating the rights of their patients.²¹ As Notre Dame ethics and political science professor O. Carter Snead states, the right to refuse medical intervention “is rooted in the common law of battery, which forbids unwanted touching by others. Upon this foundation, the law of informed consent was erected as an additional protection for bodily integrity, specifically in the context of medical care.”²² Chief Justice William Rehnquist quotes a New York Court of Appeals justice in Cruzan as aptly describing this legal doctrine: “Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent commits an assault, for which he is liable in damages.”²³

However, the real-world consequences for defying a DNR seem less motivating than the perceived risks of letting a patient die. Raphael quotes legal professionals in her New York Times article stating lawsuits in this scenario are rare. Compensation lawsuits are calculated on loss of wages, and elderly patients do not offer the possibility of a large payout. Though it is inarguable some patients have been wronged, it is not a category of wrong anyone feels motivated to punish.

Decisions Must Be Made

There is no doubt CPR, intubation, and defibrillators save lives. Though the exact numbers of lives saved per year in the United States are difficult to calculate, the American Heart Association (AHA) categorically states, “CPR is a lifesaving intervention and the cornerstone of resuscitation from cardiac arrest. Survival from cardiac arrest depends on early recognition of the event and immediate activation of the emergency response system.”²⁴ AHA also claims 100,000 or more lives could be saved every year if more people were trained in the proper performance of CPR.

Perhaps one reason resuscitation efficacy is so misunderstood is that cardiac arrest is so shockingly fatal. According to the Red Cross, “Each year EMS [Emergency Medical Services] cares for more than 350,000 individuals in the United States experiencing a non-traumatic out-of-hospital cardiac arrest (OHCA). Approximately 90% of persons who experience an OHCA die.”²⁵ The best chance for survival for anyone facing OHCA is the immediate application of CPR and the use of a defibrillator. Resuscitation techniques are a bridge to more intensive medical intervention,²⁶ but is it a bridge every human being is morally required to attempt to traverse in what will likely be their last moments this side of heaven? Absolutely not.

This subject is difficult to discuss. While preparing to write this article, I talked to a few people about it. One older friend responded, “Are you in a hurry for me to die?” Another person perceived my conversation as encouraging people to enact DNRs. This is why this conversation is hard. We are discussing the end of our days living among the people we love, and DNRs can feel like giving up. I clarified my only wish is for people to have an open and frank conversation with their doctors about what resuscitation efforts entail and for them to make an informed personal decision.

Philosopher Christopher Tollefsen and medical doctor Farr Curlin wrote a book encouraging the medical profession to abandon both a paternalistic medical approach and the service-provider approach for what they term “The Way of Medicine,”²⁷ a focus on medicine as a practice and calling oriented toward the health and flourishing of their patients in a cooperative effort to attend to human goods. The doctor is neither the stern prescriber of all that is best nor the feckless retailer answering the demands of an insistent customer. Medical decisions should be made by determining what is best for the individual. Snead argues similarly when he writes that medical professionals must deal with each patient as an embodied being and not simply a body.²⁸ Pope John Paul II echoed this sentiment, writing, “Certainly there is a moral obligation to care for oneself and to allow oneself to be cared for, but this duty must take account of concrete circumstances. It needs to be determined whether the means of treatment available are objectively proportionate to the prospects for improvement.”²⁹ Every human being is the image bearer of God, and the medical decisions for each must be crafted specific to their needs as a whole human and not merely an atomized being to be treated based entirely through efforts to prolong biological life.

The Way of All Flesh

In the 2015 live-action remake of Cinderella, the king finds out he is dying. When his son, the prince, looks plaintively toward him, the king lovingly responds, “The way of all flesh, boy.”³⁰ He then lives long enough to see his son fall in love and become his own man. As he dies, his son crawls into bed with his father and lies next to him. The scene communicates something profound, dying need not be an agonizing battle for every last breath. It can be a transition. One person may wish to rage against the dying of the light, another may wish to naturally move on to the next part of the journey.

As the apostle Paul writes in 1 Thessalonians 4:13, we are not to grieve like those who have no hope. He writes in Philippians 1:21–23, “to live is Christ,” spreading grace and mercy in our lives as Jesus did in His, but “to die is gain” — “to depart and be with Christ, which is better by far.”³¹ In 2 Timothy 4:6–8 he writes his end is near, he has “fought the good fight,” finished his race, “kept the faith,” and is ready to be received into his reward through his Lord. His reward, he writes, is the same for all those who long for the appearance of Christ.

Life is precious. It is a gift of inestimable value and ought to be protected. But the king from Cinderella is right, the way of all flesh inevitably leads to our earthly death. The Lord graciously gave ample scriptural reassurances that our death opens a door to something new and beautiful. We fight for life because it is our privilege to participate in God’s divine plan to redeem the lost, to love the Lord our God, and to love our neighbor as ourselves. And yet we also face our earthly end like those who have hope. DNRs, properly understood, simply offer us the choice to decide, as death naturally approaches, to forgo the final intensive effort to prolong our days this side of heaven.

Jay Watts is the founder and president of Merely Human Ministries, Inc., an organization committed to equipping Christians and pro-life advocates to defend the intrinsic dignity of all human life.

NOTES

1. “Orders Not to Attempt Resuscitation (DNAR),” AMA Code of Medical Ethics, AMA Principles of Medical Ethics: I, IV, VIII, accessed April 14, 2025, https://code-medical-ethics.ama-assn.org/ethics-opinions/orders-not-attempt-resuscitation-dnar#.
2. David J. Casarett, Carol B. Stocking, and Mark Siegler, “Would Physicians Override a Do-Not-Resuscitate Order When a Cardiac Arrest Is Iatrogenic?,” Journal of General Internal Medicine 14 (1999), https://pmc.ncbi.nlm.nih.gov/articles/PMC1496446/pdf/jgi_278.pdf.
3. Ghania Haddad, Timmy Li, Danielle Turrin et al., “A Descriptive Analysis of Obstacles to Fulfilling the End of Life Care Goals Among Cardiac Arrest Patients,” Resuscitation Plus 8 (2021), https://doi.org/10.1016/j.resplu.2021.100160.
4. O. Carter Snead, What It Means to Be Human: The Case for the Body in Public Bioethics (Harvard University Press, 2020), 236.
5. Press Release, “Patients Overestimate the Success of CPR,” BMJ Group, July 13, 2020, https://bmjgroup.com/patients-overestimate-the-success-of-cpr/.
6. Kate Raphael, “Doctors Saved Her Life. She Didn’t Want Them To.,” The New York Times, August 26, 2024, https://www.nytimes.com/2024/08/26/well/patients-dnr-orders-ignored.html.
7. Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition, United States Conference of Catholic Bishops, June 2018, 21, https://www.usccb.org/resources/ethical-religious-directives-catholic-health-service-sixth-edition-2016-06_0.pdf.
8. Pope John Paul II, Evangelium Vitae, March 25, 1995, https://www.vatican.va/content/john-paul-ii/en/encyclicals/documents/hf_jp-ii_enc_25031995_evangelium-vitae.html.
9. Holland Kaplan, “Code Blues: When Is CPR Not Useful?,” Baylor College of Medicine, February 22, 2019, https://blogs.bcm.edu/2019/02/22/code-blues-when-is-cpr-not-useful/.
10. Jaclyn Portanova, Krystle Irvine, Jae Yoon Yi, Susan Enguidanos, “It Isn’t Like This on TV: Revisiting CPR Survival Rates Depicted on Popular TV Shows,” Resuscitation 96 (2015): 148–50, Pub Med, August 2015, https://pubmed.ncbi.nlm.nih.gov/26296584/.
11. Clayton Dalton, “For Many, a ‘Natural Death’ May Be Preferable to Enduring CPR,” NPR, May 29, 2023, https://www.npr.org/sections/health-shots/2023/05/29/1177914622/a-natural-death-may-be-preferable-for-many-than-enduring-cpr.
12. Peter A. Meaney, Bentley J. Bobrow, Mary E. Mancini et al., “Cardiopulmonary Resuscitation Quality: Improving Cardiac Resuscitation Outcomes Both Inside and Outside the Hospital,” AHA Consensus Statement, Circulation 128 (2013): 417–435, AHA Journals 2013, https://www.ahajournals.org/doi/pdf/10.1161/CIR.0b013e31829d8654.
13. “Video Affects End-of-Life Decisions,” Harvard Medical School, December 10, 2012, https://hms.harvard.edu/news/video-affects-end-life-decisions.
14. Patrick Druwé, Koenraad G. Monsieurs, James Gagg et al., “Impact of Perceived Inappropriate Cardiopulmonary Resuscitation on Emergency Clinicians’ Intention to Leave the Job: Results from a Cross-Sectional Survey in 288 Centres Across 24 Countries,” Resuscitation 158 (2021): 41–48, Science Direct, https://www.sciencedirect.com/science/article/abs/pii/S0300957220305645.
15. Ken Murray, “Death with Dignity: How Doctors Die,” UTNE Reader, April 12, 2012, https://www.utne.com/mind-and-body/death-with-dignity-zm0z12mjzros/.
16. Raphael, “Doctors Saved Her Life.”
17. Kaplan, “Code Blues: When Is CPR not useful?”
18. Casarett, Stocking, and Siegler, “Would Physicians Override a Do-Not-Resuscitate Order When a Cardiac Arrest Is Iatrogenic?”
19. Raphael, “Doctors Saved Her Life.”
20. Haddad et al., “A Descriptive Analysis of Obstacles to Fulfilling the End of Life Care Goals Among Cardiac Arrest Patients.”
21. Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 (1990), Library of Congress, https://tile.loc.gov/storage-services/service/ll/usrep/usrep497/usrep497261/usrep497261.pdf.
22. Snead, What It Means to Be Human, 236.
23. Cruzan v. Director, Missouri Department of Health.
24. Meaney et al., “Cardiopulmonary Resuscitation Quality.”
25. “CPR Facts & Statistics,” American Red Cross, March 27, 2025, https://www.redcross.org/take-a-class/resources/articles/cpr-facts-and-statistics#.
26. Dalton, “For Many, a ‘Natural Death’ May Be Preferable to Enduring CPR .”
27. Farr Curlin and Chrsitopher Tollefsen, The Way of Medicine: Ethics and the Healing Profession (University of Notre Dame Press, 2021).
28. Snead, What It Means to Be Human, 68.
29. Pope John Paul II, Evangelium Vitae.
30. Cinderella, directed by Kenneth Branagh, screenplay by Chris Weitz, based on the fairy tale written by Charles Perrault (Walt Disney Studios, 2015).
31. Bible quotations are from the NIV.