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A terminal geriatric patient has just arrived by ambulance for hospital readmission. At first glance, it’s clear she has declined significantly since last seen. But she has a history of being a fighter who has tolerated many treatments, complicating the clinical picture. How do you talk with her, as her condition deteriorates, about her wishes regarding resuscitation?
The question is one that physicians across Europe face daily — with widely varying tools, training, and institutional support behind them. For many, clarifying whether a patient wants to be resuscitated in the event of cardiac arrest — and why that might be a medically unrealistic goal — is a daunting conversation. In many countries, it is a mandatory one. Yet evidence shows that how, and how often, these discussions take place varies enormously, shaped by geography, training, culture, and the strength of legal frameworks governing end-of-life care.
“In the UK, we aim to discuss [resuscitation] on admission,” Mary Ni Lochlainn, MB BCh BAO, clinical lecturer in geriatric medicine at King’s College London, London, England, told Medscape News Europe.
But institutional policies aren’t always comprehensive or clear enough to help doctors navigate the ethical nuances that can arise — and the data suggests that gap in guidance translates directly into wide variability in practice.
A Continental Divide
A 2025 study of geriatricians in Europe found that those with more experience and those working in Western Europe were significantly more confident about holding do-not-resuscitate (DNR) discussions. The survey of 473 clinicians across 22 countries revealed that Western European geriatricians held these talks more frequently than their peers in other parts of the continent. Female physicians were also significantly more likely to initiate these conversations.
The study identified several systemic barriers to these discussions, including time constraints (reported by 50%), a lack of formal training (41%), and cultural beliefs (25%). Some respondents (38%) reported that cardiopulmonary resuscitation (CPR) would still be performed at the request of patients or their families, despite the medical team determining that it offered no clinical benefit.
“Discussions about ‘do not attempt cardiopulmonary resuscitation’ always depend on culture and context,” Kasper G. Lauridsen, MD, PhD, associate professor of clinical medicine and associate professor of resuscitation science at Aarhus University, Aarhus, and Randers Regional Hospital, Randers, both in Denmark, told Medscape News Europe. “In Denmark, many patients have strong opinions about not wanting CPR in case of cardiac arrest, while other patients have not thought about it yet. Thus, my perspective before the conversation is, do I think CPR could be an appropriate treatment for this patient?”
Expectations vs Clinical Realities
These challenges intensify when patients misunderstand resuscitation as a standard treatment rather than an emergency intervention with significant medical ramifications.
“Healthcare providers generally agree on when CPR should be performed and, just as importantly, when it is unlikely to be beneficial — such as in patients with advanced, terminal illness,” Mohammad Zafir Al-Shahri, MD, consultant of palliative care medicine at King Faisal Specialist Hospital and Research Center Cancer Center of Excellence and adjunct professor at Alfaisal University College of Medicine, both in Riyadh, Saudi Arabia, told Medscape News Europe. “However, unlike many other interventions, CPR occupies a unique space in both medicine and society. One reason for this is the widespread public perception of CPR, shaped in part by media portrayals that significantly overestimate its success rates. As a result, expectations around CPR often differ from clinical realities.”
Patients’ families also weigh in with their opinions. The result can be patients requesting that resuscitation is listed on their records even though it might simply postpone an imminent death. In these cases, doctors need to proceed with empathy and realism.
“Sensitive and appropriate discussions usually resolve any issues where families or patients would like full resuscitation, but which we believe would be futile,” said Lochlainn. “Usually, explaining the low success rate of CPR and the detail involved in resuscitation — for example, the likely need for a breathing tube and the patient having to go to the intensive care unit — can be helpful for giving a fuller picture of the process. This is not always known to patients and families, especially as it is not very accurately represented on TV and in films. With this kind of additional detail and good communication skills, a mutual decision is often achievable.”
In practice, the reverse situation — a physician considering resuscitating a patient who has explicitly requested a DNR order — is very rare.
“We honor the patient’s wishes,” said Lochlainn. “I have never seen a case of a patient wanting DNR who did not have a clear reason to do so, such as age, frailty, or disease.”
The Legal and Institutional Landscape
Consistent legal frameworks can make these conversations considerably easier to navigate.
“In most areas of medicine, treatment decisions follow a clear standard of care,” said Al-Shahri. “Clinicians present appropriate options, discuss their risks and benefits, and arrive at a shared decision with the patient. Importantly, interventions that are not medically indicated are typically not offered or discussed.”
The required approach varies significantly by country, however. “In some countries, clinicians are required to discuss CPR preferences with patients or their surrogates, particularly when a ‘do not attempt resuscitation’ decision is being considered,” said Al-Shahari. “In others, decisions may be primarily clinician-led, with varying degrees of patient involvement. In yet other settings, CPR is performed by default unless there is a clear directive otherwise. Given this variability, clinicians are expected to follow the policies and legal frameworks of their institutions and regions when deciding how and when to initiate these discussions.”
The challenge of practicing without clear legislative guardrails is well-documented. A 2024 study of physicians in Greece — a country with no legal framework for DNR — found that 94.5% of respondents supported introducing legislative regulation and a formal DNR document for end-stage and critically ill patients.
ERC Guidelines 2025: Key Ethics in Resuscitation
The European Resuscitation Council 2025 Guidelines emphasize a patient-centered approach to end-of-life care.
- Advance care planning: Should be offered by healthcare systems to all patients at risk for cardiac arrest, integrating DNR decisions into the broader goals of care.
- Regular reassessment: Advance care plans must be reviewed regularly, especially when a patient’s clinical situation changes.
- Communication training: Ethical reasoning and communication skills are considered “core competencies” and should be integrated into formal resuscitation training.
- Termination of resuscitation: Decisions to end CPR should be team-based, using a holistic approach that considers patient preferences and prognostic factors.
- Standardized documentation: Systems should use electronic registries or standardized templates to ensure DNR orders are accessible in emergency settings.
A Practical Approach to the Conversation
Any discussion about a patient’s resuscitation wishes should maintain a humane tone throughout.
“Discussions about CPR should be approached with sensitivity, clarity, and honesty,” said Al-Shahri. “They should focus on the patient’s overall condition, goals of care, and what outcomes are realistically achievable. When done well, these conversations are not simply about a procedure, but about aligning medical care with what matters most to the patient.”
“My opening question is usually along the lines of, ‘Have you thought about what should happen if your heart stops beating?’” Lauridsen said. “After I ask that question, the situation is either settled or we have to talk about what exactly a resuscitation attempt entails, what would be possible and what would not be, and the likely outcomes.”
The patient should also know when resuscitation will not extend their life despite a team’s best efforts. “Ultimately, it's a medical decision whether to offer resuscitation or not, as we don't offer treatments we don't think will be successful,” said Lochlainn. “However, we always must include the patient in this decision-making, and their next of kin should ideally be involved too.”
“For terminally ill patients specifically, it may be more important to discuss end-of-life care and how they wish their last moments to be,” Lauridsen said. “In discussing this, it usually becomes quite apparent that a sudden cardiac arrest is a good way to end the journey.”
Lochlainn, Lauridsen, and Al-Shahari reported having no relevant financial relationships.
