DNAR as Default Status: Desirable in Principle, Difficult in Practice

Barbara Daly , an oncology nursing professor at Case Western, has a short piece in the July 2008 American Journal of Critical Care,in which she argues for a reversal of the current norm which presumes that every patient gets CPR unless there is a specific physician order (e.g. DNAR, POLST) to the contrary.

Specifically, Daly wants to "restrict use of CPR to those patients who provide adequately informed consent and for whom CPR has a reasonable 
 chance of success (discharge from the hospital without significant impairment in cognitive status.)"  This argument to reverse the default 
 status has been pushed for many years, and I am sympathetic to it. But while Daly raises and cogently responds to five important objections, she 
 leaves a rather central issue untouched. 

 Daly exempts from her proposal those patients for whom there is a "meaningful chance of producing a desirable outcome."   But this phrase, 
 like those in her proposal, contains extremely vague and value-laden terms. Specifically, why is "discharge from the hospital without significant 
 impairment" the right measure of success? What is a "reasonable" or meaningful chance?  For more than twenty years the medical community has 
 tried and failed to reach consensus on any definition of "quantitative  futility" or "qualitative futility." 

 Therefore, while attractive, it will be difficult to operationalize Daly's proposal until we can adequately answer three very difficult 
 questions: 

1. What is the threshold that defines "reasonable chance of success"?
2. Should CPR even be disclosed as an option to patients below the threshold?
3. Should CPR be provided, when demanded, to patients below the threshold?