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January 19, 2000

The Hospitalist's Role in Advance-Care Directives

Author Affiliations

Phil B.FontanarosaMD, Deputy EditorIndividualAuthorMargaret A.WinkerMD, Deputy EditorIndividualAuthorStephen J.LurieMD, PhD, Fishbein FellowIndividualAuthor

JAMA. 2000;283(3):336-337. doi:10-1001/pubs.JAMA-ISSN-0098-7484-283-3-jac90010

To the Editor: Dr Pantilat and colleagues1 described ethical issues presented by the hospitalist system. They describe a patient who desires "only comfort care" when her condition worsens. Her primary care physician wrote an outpatient do-not-resuscitate (DNR) order that stated "does not want [cardiopulmonary resuscitation] CPR for cardiac arrest." In our opinion, this order, in isolation, did not adequately reflect the wishes of the patient and created the hospitalist's dilemma. When the patient's condition became unstable, and required mechanical ventilation and vasopressors, the hospitalist overrode the DNR order by initiating these treatments. There are 2 separate issues in this case. First, there was no report of a cardiac arrest, but the patient did need treatment and support for a potentially reversible condition (pulmonary embolism) despite her underlying malignancy. Second, little documentation was available to the hospitalist about the meaning of the DNR order or its implications for other treatment decisions.