In their assessment of CPR-not-indicated proposals, Waisel and Truog [1] conclude that "policies based on anything other than physiologic futility are indefensible," adding that physiologic futility "is a symbolic statement" that "does little to advance current practice management." For the house officer, such conclusions have little value. As the person who must carry out the word of any directives, the house officer is often caught in the middle of decisions on resuscitation.

Physiologic futility as a guideline for CPR-not-indicated policies has several drawbacks. First, physiologic futility is difficult to assess before implementing resuscitative measures. Second, when the patient reaches a point at which further measures would not restore physiologic function, the patient is already dead. Third, physiologic futility already exists, permitting the physician to "call a code." Thus, for the house officer, physiologic futility is an impractical approach.

In any policy for CPR-not-indicated orders, the direct relation of the house officer to the resuscitation decision sets up the possibility for conflict between housestaff values and patient or family wishes. Some of these conflicts are resolved by a "slow code," a practical but unethical resolution of the conflict in which physicians fail to inform families of their intention not to resuscitate. Patients and families must be aware of our plans and must be encouraged to seek alternate physicians when intentions differ. Housestaff should be involved in all levels of discussion.

A role exists for unilateral do-not-resuscitate orders and cogent definitions of futility. Decreasing stays in the intensive care unit will yield some cost savings. Public mistrust exists amid the suspicion of clandestine decision making. Concern for value judgments should be tempered by the knowledge that physicians make such judgments regularly when offering and withholding treatments. In the final analysis, fidelity, nonmaleficence, and utility supersede the concerns of paternalism in the decision to apply unilateral CPR-not-indicated orders.