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What is the true definition of a "Do-Not-Resuscitate" order? A Japanese perspective

Authors Hiraoka E, Homma Y, Norisue Y, Naito T, Kataoka Y, Hamada O, Den Y, Takahashi O, Fujitani S

Received 29 January 2016

Accepted for publication 12 April 2016

Published 29 June 2016 Volume 2016:9 Pages 213—220

DOI https://doi.org/10.2147/IJGM.S105302

Checked for plagiarism Yes

Review by Single-blind

Peer reviewers approved by Dr Lucy Goodman

Peer reviewer comments 2

Editor who approved publication: Dr Scott Fraser


Eiji Hiraoka,1 Yosuke Homma,2 Yasuhiro Norisue,3 Takaki Naito,1 Yuko Kataoka,1 Osamu Hamada,1 Yo Den,1 Osamu Takahashi,4 Shigeki Fujitani3

1Department of Internal Medicine, 2Department of Emergency Medicine, 3Department of Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan; 4Department of Internal Medicine, St Luke’s International Hospital, Tokyo, Japan


Background: Japan has no official guidelines for do-not-resuscitate (DNR) orders. Therefore, we investigated the effect of DNR orders on physician decision making in relation to performing noncardiopulmonary resuscitation (CPR) and CPR procedures.
Methods: A case-scenario-based questionnaire that included a case of advanced cancer, a case of advanced dementia, and a case of nonadvanced heart failure was administered to physicians. The questions determined whether physicians would perform different non-CPR procedures and CPR procedures in the presence or absence of DNR orders. The number of non-CPR procedures each physician would perform and the number of physicians who would perform each non-CPR and CPR procedure in the absence and presence of DNR ocrders were compared. Physicians from three Japanese municipal acute care hospitals participated.
Results: We analyzed 111 of 161 (69%) questionnaires. Physicians would perform significantly fewer non-CPR procedures in the presence of DNR orders than in the absence of DNR orders for all three case scenarios (median [interquartile range] percentages: Case 1: 72% [45%–90%] vs 100% [90%–100%]; Case 2: 55% [36%–72%] vs 91% [63%–100%]; Case 3: 78% [55%–88%] vs 100% [88%–100%]). Fewer physicians would perform non-CPR and CPR procedures in the presence of DNR orders than in the absence of DNR orders. However, considerable numbers of physicians would perform electric shock treatment for ventricular fibrillation in the presence of DNR orders (Case 1: 26%; Case 2: 16%; Case 3: 20%).
Conclusion: DNR orders affect physician decision making about performing non-CPR procedures. Although some physicians would perform CPR for ventricular fibrillation in the presence of DNR orders, others would not. Therefore, a consensus definition for DNR orders should be developed in Japan, otherwise DNR orders may cause harm.

Keywords: code status, do-not-resuscitate order (DNR)

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