The ethical hierarchy of do not resuscitate orders: Never say never

Mrs G. Oner, a 58-year-old woman, had a massive myocardial infarction after an aneurysmectomy being kept alive for several weeks by a left ventricular assist device. It appears that she may survive. However, Mrs Oner has become clinically depressed and is strongly considering discontinuing hemodynamic support. After a discussion about her condition during which she learned that survival could not be assured, she elected what the hospital calls “code two” do not resuscitate (DNR) status (no cardiopulmonary resuscitation, no intubation) but wants all other treatment to continue “as long as it will help her.” She did not discuss this decision with her husband, an internationally acclaimed professor of law, beforehand. When he visits later that day, she unexpectedly has a stroke accompanied by respiratory difficulty and Professor Oner insists that “everything” be done. The team informs him that the patient will not be intubated, per the code two status. He insists that he is her legal surrogate and demands the DNR status be withdrawn. Which options are unethical?AThe husband is Mrs Oner's legal surrogate. He can order a change in the DNR status.BThe professor will likely sue. Intubate.CThe DNR status, regardless of the circumstances, stands legally and ethically.DThe DNR is invalid because the spouse was not informed of the change.EThe DNR should be suspended until the patient's neurologic status is determined