Beyond resuscitate and do-not-resuscitate

We applaud Hebert and Selby1 for examining the difficulties of responding to iatrogenic or potentially readily reversible critical incidents in patients with a do-not-resuscitate order. Several Canadian health authorities have already replaced do-not-resuscitate orders with more nuanced medical order frameworks (Goals of Care Designations2 in Alberta and Medical Orders for Scope of Treatment3 at Fraser Health, BC) to better reflect patient values and medical care appropriate to their context.

These medical orders are determined through a process of communication between a patient, surrogate decision-makers and health care providers. The orders convey information about the types of interventions to be used or withheld, the location of care and most importantly the general intention of care. System-wide policies and procedures ensure that the order and documented discussions travel with the patient. These frameworks are implemented with advance care planning initiatives4 normalizing early reflection and communication, which can assist in health care decision-making.

Although not a panacea for ethical dilemmas, such frameworks greatly inform decision-making. They are an improvement over binary resuscitate or do-not-resuscitate orders and prior conversation details buried in health records.