Summary

A patient with a history of metastatic bronchial carcinoma and end stage heart disease was admitted to hospital, after an accidental fall, because of epistaxis requiring nasal tamponade and blood transfusions. On day 2 the patient suffered from acute dyspnoea and finally respiratory and cardiac arrest. The patient was successfully resuscitated despite a do not resuscitate order (DNR order). A bolus aspiration of the nasal tamponade’s gauze was discovered as the reason for the arrest. This case report underlines the ethical dilemma in patients with an otherwise undisputed DNR order when the arrest is: (1) easy to resolve but not easy to detect; (2) iatrogenic in nature; and (3) is occurring in an unmonitored area (for example, the ward) as compared with an arrest in a well monitored area (for example, the intensive care unit and operating room).