Not For Resuscitation Orders: Review of Dr. Tonti-Filippini's book "Caring for People Who are Sick or Dying"

William E. May
October 11, 2012
© Culture of Life Foundation 201
Reproduced with Permission
Culture of Life Foundation

Nicholas Tonti-Filippini, a highly respected Australian bioethicist known for his presentation and defense of Catholic teaching, offers a helpful presentation of the meaning of "Not for Resuscitation Orders" (henceforth referred to as NFR) in Vol. 2, Caring for People Who Are Sick or Dying (pp.76-79), the 2nd of his projected 7 volume series About Bioethics. Tonti-Filippini defines the basic meaning of resuscitation, summarizes facts about resuscitation efforts and their effects on people, particularly the frail, the elderly and persons suffering from a disease soon to end in death. He then affirms the right of a competent person, or, if incompetent, his/her authorized health-care agent or doctor, to determine whether a treatment is futile or unduly burdensome as well as the right to refuse such treatment and demand that it be withheld or withdrawn. The final pages (78-79) of his presentation clearly summarize the central issues involved in making morally justified NFR decisions.

The basic meaning of "resuscitation," its effects on people, their right to refuse futile or unduly burdensome treatments

"Resuscitation" refers to interventions after cardiac or pulmonary arrest. These can include the following: putting a tube into the obstructed airway; defibrillation, i.e. using a device called a "defibrillator" to deliver an electric shock to restart the heart or restore its rhythm; adrenaline to stimulate the heart; massaging the heart both to restart it and to compress the lungs to assist breathing; giving a large dose of valium "so that the patient will not remember the awful experience"; and in hospitals at times attaching a ventilator to the breathing tube. Most attempts to resuscitate do not succeed. Success is most frequent closely following cardiac arrest during or after surgery, drowning, and after a fall on one's head - notably incidents and not pathologies. But success is rare if the person suffers cardiac arrest or stops breathing because of advanced heart disease or cancer (e.g. congenital heart failure). It is therefore normal practice not to resuscitate if the person is suffering a disease soon to end in death or if the effort is regarded as futile.

Because efforts to resuscitate are very intrusive (e.g., cardiac massage often breaks ribs, particularly in the frail and elderly, defibrillation is something "nobody would want to experience while at all conscious") one may judge that resuscitation is overly burdensome for some who are very frail, and yet an NFR order will be made "even though resuscitation might not be futile." Moreover, many who have been resuscitated for respiratory failure have made it known that they do not want to have resuscitation attempted again because they judge it overly burdensome, and "it is their moral and legal right to refuse it" (see comments below). However, an NFR order is not a "death sentence in which all forms of life-prolonging care are withdrawn [or withheld]. Ordinary or relatively non-burdensome treatments such as antibiotics for existing infections and tube feeding should normally be continued. While an NFR order should not preclude ordinary assistance for a temporary problem, such as clearing a blocked airway after a person has choked on food" (pp. 77-78).


Tonti-Filippini has identified certain attempts to resuscitate as "futile." In which cases such attempts can morally be withheld or withdrawn - in fact, to insist on their use can be a form of "vitalism," the mistaken claim that one must use every medically available means to prolong and/or preserve human life. Such a claim can be morally unjust not only because it may be burdensome to the patient but also because it inevitably brings about an increase in the premiums people must pay for their health insurance (or that governments may subsidize through the use of tax monies), thereby imposing severe burdens on families, in particular low-income families with children. All pro-life bioethicists agree that such futile treatments are "disproportionate" or "extraordinary" and need not be used.

Toni-Filippini also calls some treatments unduly burdensome - and imposing treatments on persons that are unduly burdensome is another kind of "disproportionate" or morally "extraordinary" medical treatment. Since Tonti-Filippini's presentation on p. 78 is very brief, some comments on the objective criteria to show that at times medical treatments are from a moral perspective "unduly burdensome." In judging whether this is the case, it is "proper," as a Vatican document maintains, "to take into account the state of the sick person and his or her physical and moral resources." It is always gravely immoral to intentionally kill a person for merciful reasons (i.e., to commit euthanasia) because one judges that this person's "quality of life" is so wretched that he or she is better off dead than alive.[1] But it is legitimate to consider this particular person's "quality of life" (=his or her "state…and his or her physical and moral resources") in judging a medical treatment morally "extraordinary/disproportionate."

Central Issues in making morally justified NFR decisions

Tonti-Filippini identifies these as indications, consultation, and documentation. He declares that a NFR order can be [rightly] ordered when;

  1. A patient of sound mind and free of any suicidal ideation or temporary depression, and in possession of the relevant medical information about his or her condition, makes a competent decision, free from any coercion by others, to refuse resuciative interventions that he or she would consider to be overly burdensome or futile (unlikely to succeed) were he or she to arrest.
  2. The patient's legally recognized representative for medical treatment decisions, in possession of the relevant medical information about the patient's condition, has reasonable grounds for believing that the patient, if competent, would refuse resuscitative efforts on the grounds that they would be overly burdensome or futile were he or she to arrest, or;
  3. The patient's doctor judges that the patient's condition is such that, in the event of an arrest, attempts to resuscitate would be futile or would in themselves be overly burdensome for the person.(pp. 78-79)

Tonti-Filippini concludes by saying that an NFR order, to be valid, must include the date issued, a date for review (no more than six months), names of persons consulted, the indications leading to the order, treatment to be continued such as to clear blocked airways and continued use of antibiotics for existing conditions, specific measures to be withheld (e.g., attempting cardiac message), and the doctor's signature and contact information.


I believe Tonti-Filippini's discussion of this matter is very helpful and would be good to be kept in mind by health care workers, pro-life patients and their relatives.