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March 17, 1989

Reappraisal of DNR Orders in Long-term-Care Institutions-Reply

JAMA. 1989;261(11):1582-1583. doi:10.1001/jama.1989.03420110056017

In Reply.—  Dr Kerr shares some important observations about the use of CPR in the patient population served in his own 120-bed nursing care facility. Like Dr Murphy,1 he used his clinical experience and knowledge of the relevant literature to be "more direct in counseling patients and families to forgo CPR when it was not medically indicated." As in the case in Dr Murphy's institution, the results were gratifying: the CPR rate dropped dramatically.I would modify his comments in two respects. First, my suggestion that 5 more days of life might be valued by a patient (for example, to say good-byes) obviously would not apply to a severely demented patient incapable of social interaction. Second, Dr Kerr uses the term "vanishingly rare" as a means for identifying interventions for which a good outcome is sufficiently unlikely that they can be ruled out on "medical grounds" alone. Clinicians should