Choosing between life and death: Patient and family perceptions of the decision not to resuscitate the terminally ill cancer patient

In keeping with the pre-eminent status accorded autonomy within Australia, Europe, and the United States, medical practice requires that patients authorize do-not-resuscitate (DNR) orders, intended to countermand the default practice in hospitals of instituting cardiopulmonary-resuscitation (CPR) on all patients experiencing cardio-pulmonary arrest. As patients typically do not make these decisions proactively, however, family members are often asked to act as surrogate decision-makers and decide on the patient's behalf. Although the appropriateness of patients or their families having to decide about the provision of CPR has been challenged, there has been little examination of how patients and their families talk about and negotiate such decisions, particularly in the context of the patient's imminent death. In this article, part of a larger study analysing interviews with 28 patients (13 female) with cancer within weeks of their death, and 20 others (predominantly family) attending, we argue that a common assumption underpinning participants' talk about the DNR decision (i.e. forgoing CPR) is that it requires a choice between life and death. Using illustrative examples, we demonstrate that in making decisions about CPR, patients and their families are implicitly required to make moral judgements about the value of the patient's life, including their relationships with significant others. We identify some implications of these empirical observations for the development of ethically appropriate policies and practices regarding patient autonomy and surrogacy at the end of life.