To the Editor.
—The recent update of the cardiopulmonary resuscitation guidelines1 and editorial comment2 are welcome as further developments in this complicated and evolving area. However, many specific problems were not addressed. Truog3 reviewed the question of the status of DNR orders in patients undergoing surgery and anesthesia. For anesthesiologists, there are special and frequently conflicting aspects of providing care during palliative surgery. The following case highlights this dilemma:A 54-year-old man with endstage amyotrophic lateral sclerosis presented for gastrostomy. He was fully alert but confined to a wheelchair. He lived at home with his caring wife. His profound weakness did not permit coordinated swallowing, and his decline was being accelerated by malnutrition. Respiratory reserve was negligible with PaO2 of 56 mm Hg breathing air and PaCO2 of 54 mm Hg. In a discussion prior to the procedure, the patient and his wife revealed an