Do not Resuscitate (DNR) Order

Definition
Purpose
Description
Preparation
Normal results

Definition

A do not resuscitate (DNR) order is a kind of advanced medical directive allowed by a 1991 federal law. The law expanded the notion of patient autonomy to situations in which patients may not be able to make crucial medical decisions due to incapacitation. A DNR order instructs medical personnel not to perform lifesaving cardiopulmonary resuscitation (CPR) or other procedures to restart the heart or breathing once it has ceased. By law, the DNR directive must be offered as an option to patients by health providers in and, in some states, outside a hospital setting. Once signed, the DNR directive must be placed in the patient’s chart.

Purpose

With such advanced cardiopulmonary techniques as CPR, it is possible to keep almost any patient’s heart and lungs functioning, independent of how terminal or hopeless his or her medical condition becomes. The DNR program is designed to help people in the final stages of a terminal illness or those who are suffering from intractable pain the option for deciding against life-saving measures that may only prolong their pain and inevitable death. The option of deciding against life-saving measures is considered to be a formal part of patient autonomy and is respected as an ethical subset of medical informed consent.

Description

DNR orders affect a small group of patients and are designed to avoid the suffering of a terminal illness or other serious conditions that are medically irreversible. The order actually authorizes medical treatment to be

KEY TERMS

Advanced medical directive— A legal document drafted by a patient, in advance, ordering specific medical procedures to be offered or withheld if they are incapacitated.

Cardiopulmonary resuscitation (CPR)— A set of medical procedures used in an emergency to restart the heart and lungs.

Medical agent— A designated representative for the patient who, in advance, is legally empowered to carry out their wishes with respect to medial care.

Medical surrogate— Another name for a medical agent or person legally designated to represent the patient with medical providers.

withheld. It is included with the medical orders in the medical chart, and with it, hospital and pre-hospital personnel are restricted from using CPR techniques and other measures to revive the patient.

Some states allow DNR orders only in hospital settings. Other states allow DNR orders to be honored by emergency responders working outside the hospital setting. Over half of the states in the United States have pre-hospital DNR orders. A physician must sign the pre-hospital DNR directives. The state’s emergency medical service (EMS) department or state medical association administers the programs. In some states, the DNR may be called a pre-hospital medical care directive or a comfort care-only document.

A DNR order can be revoked at any time in any way that effectively communicates the patient’s desire. It can come from the patient in the form of a letter or document. It can come from the patient telling an emergency provider to disregard the order. The revocation can be invoked by removing any bracelet or medallion that indicates DNR status. It can be communicated by the designated health agent or patient representative who has the power to express the patient’s wishes to health providers. Some states maintain a registry for individuals with DNR orders. It is important to find out about a state’s service for DNR and its particular legal forms and requirements. Many patients who die in a hospital have had a DNR order.

Preparation

Do not resuscitate orders are a part of advanced medical directives. Advanced directives are legal documents that place limits on medical treatment, guide medical providers on the wishes and options of the patient, and help family members and providers make decisions in accordance with the patient’s wishes. Advanced directives are prepared in advance and may include a living will that details the patient’s wishes should he or she become incapacitated. A DNR order is a very specific order that medical treatment be withheld, especially CPR. Finally, a medical agent or a person with a durable medical power of attorney is usually appointed to carry out all wishes of the patient and to make sure that specific wishes, like DNR, are honored.

An advanced directive for withholding resuscitation can be prepared by requesting a form from the physician, by writing down that wish, by having a lawyer draft a living will, or by using computer software for legal documents. States differ in the respect of whether the documents must be cosigned or notarized. Crucial to the effort is that the physician be told of the wishes of the patient.

Normal results

DNR law varies from state to state, but the common features include:

• Formal documents that providers or responders can readily recognize in charts or on display in the home.
• DNR bracelets or medallions that the patient wears and providers are trained to recognize.
• DNR must be signed by a physician before responders or other providers may honor them.
• Once in effect, DNR orders include only certain life-preserving procedures, like CPR. Comfort treatment is not withheld, and the alleviation of pain is still pursued by providers.
• Physicians or other providers who are unwilling to carry out the order (for moral or professional reasons) are required to transfer the care of the patient to another provider who will carry out the DNR order.

Resources

PERIODICALS

Kish, S.K. “Advance Directives in Critically Ill Cancer Patients.” In Critical Care Nursing Clinics North America 12 (September 1, 2000): 373–83.

Matousek, M. “Start the Conversation: The Modern Maturity Guide to End-of-Life Care” and “The Last Taboo.” Modern Maturity/AARP (September–October 2000).

ORGANIZATIONS

Cancer Information Service. (800) 4-CANCER (800-422-6237). TTY: (800)332-8615. http://www.cancer.gov (accessed March 19, 2008).

Partnership for Caring. 1620 Eye St., NW, Suite 202, Washington, DC 20006. (202) 296-8071. Fax: (202) 296-8352. Toll-free hotline: (800) 989-9455 (option 3). http://www.partnershipforcaring.org/ (accessed March 19, 2008).

OTHER

“Advanced Directives and Do Not Resuscitate Orders.” American Academy of Family Physicians. March 2002 [cited May 5, 2003]. http://familydoctor.org/handouts/003.html (accessed March 19, 2008).

“Choosing a Health Care Agent.” Healthwise WebMD Health [cited May 5, 2003]. http://www.WebMD.com (accessed March 19, 2008).

“Death and Dying.” Health Topics National Library of Medicine, NIH/MedlinePlus [cited May 5, 2003]. http://www.nlm.nih.gov/medlineplus/deathanddying.html (accessed March 19, 2008).

“Death and Dying.” In Merck Manual, Home Edition [cited May 5, 2003]. http://www.merck.com/mmhe/index.html (accessed March 19, 2008).

Nancy McKenzie, PhD

Fran Hodgkins

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