A Do Not Resuscitate (DNR) Order is a written order by a physician telling healthcare providers to not attempt to revive a patient in the case of a cardiac or respiratory arrest. A DNR order is different from a living will or a medical power of attorney because a person or patient needs a physician’s approval for a DNR order. Although it is similar in that it is the written request of a patient, their family, or a healthcare agent, a DNR order must be signed by a physician to be valid.
Why is a DNR order required to refuse CPR?
Without explicit orders from a physician to not resuscitate, a healthcare team is required to initiate CPR when there is a cardiac or respiratory arrest because in such a case, there is no time to call an attending physician or determine the person’s wishes by contacting their family or health care agent. If a person does not want CPR to be provided to them in such a scenario, they must communicate that by preparing a DNR order signed by the attending physician in advance.
If a person has a DNR order, does that mean they won’t receive any medical treatment?
No. A “do not resuscitate” order is not synonymous with “do not treat.” A DNR order specifically covers only CPR. Other types of treatment, such as intravenous fluids, artificial hydration or nutrition, or antibiotics must be separately discussed with a physician if a patient also wishes to refuse them. In addition, it is important to note that although CPR will not be performed on a person with a DNR order, all possible measures will be taken to keep them comfortable.
Who is eligible to request a DNR order?
An individual, their healthcare provider, or a family member (as provided by state law) can agree to a DNR order. Although the specifics can vary, generally a DNR order must be discussed with the person it will be for if they have the capability to make medical decisions. If a person is incapable or otherwise unable of making this decision, a physician can consult instructions in a living will or speak with an appointed healthcare agent. If there are no written directives, a physician can consult a family member or close friend of the individual to try and determine what they would have wanted.
When should someone consider a DNR order?
If a person is dying or extremely ill, it is a good idea to see a physician about obtaining a DNR order. Ideally, a decision about obtaining a DNR order should be made while the individual is lucid and able to make such decisions. However, if a person is unable to make a decision about a DNR order, it is imperative that it is discussed as soon as possible. Ideally, the physician will bring it up, but the family or healthcare agent should not to talk to the physician about this. By discussing this matter sooner rather than later, both the individual and their family can have time to reflect on the decision.
What concerns should be brought up when discussing a DNR order with a physician?
Before deciding whether CPR should be refused, an individual and their loved ones must consider both the advantages and disadvantages of CPR, which can vary depending on the individual’s condition. The physician should be prepared to discuss the procedure and the probability for successful resuscitation based upon the person’s medical condition, explain what exactly constitutes a successful resuscitation, whether or not a successful resuscitation means a person will be able to leave the hospital and, if so, in what condition. If the physician does not feel that resuscitation would be successful, they should be prepared to discuss the reasons why.
What if the individual or their healthcare agent or family disagrees with the physician’s recommendation?
First, the individual or family should talk to the physician in order to clear up any possible misunderstanding regarding the individual’s wishes, prognosis, and treatment options. They can also request a meeting with the physician, nurses, and other members of the healthcare team to discuss reasons why an agreement cannot be reached. Oftentimes, such conflicts happen because of miscommunication. If an agreement cannot be reached, it is important that the individual or their agent or family learn what resources are available to mediate and resolve such conflict.
Healthcare facilities are required to make available a process for resolving conflicts over CPR. A social worker or patient representative might be a good source of information on how to proceed. The family should also request a copy of the facility’s policy on DNR orders. The policy should describe how the facility resolves conflict. For example, many facilities will provide individuals and their family an opportunity to bring such conflicts before an ethics committee which can provide a neutral environment to mediate and resolve conflicts in.
Can a physician issue a DNR order without prior consultation with the individual?
In exceptional circumstances, yes. If a person is incapacitated and an authorized decision maker cannot be reached and depending on the facility’s policies on such matters, a physician may be able to write a DNR order if they believe that CPR would not be appropriate treatment considering the individual’s underlying illness. Generally, however, a physician is obligated to discuss a possible DNR order with the individual or their authorized decision maker, and must obtain consent before any treatment can be withheld or withdrawn, because informed consent is a basic right that a facility’s policy on DNR orders must respect.
Will DNR orders remain in effect in the case that a person is transferred between healthcare facilities, such as from a nursing home to a hospital?
Yes. The individual’s DNR order should accompany them during every transfer. Once a person has arrived at the new facility however, a new DNR order might need to be issued depending on that facility’s policy. If someone has a DNR order, it is important that family and friends monitor their transfer to ensure that the DNR order accompanies the individual and is properly documented in their medical records at the new facility, as DNR orders or other important documents, like a living will or medical power of attorney, can sometimes be misplaced or overlooked during a transfer.
Will a DNR order be honored during surgeries?
Most of the time, no. Usually, a DNR order will be suspended during surgery, because cardiac or respiratory arrest during surgery may be because of the surgery and not the underlying illness, increasing the odds of a successful resuscitation. When the individual is about to undergo surgery, it is important that they or an authorized decision maker talk to the surgeon in advance to make sure all parties understand what should be done in the case of an arrest during or immediately following the surgery. The surgeon should also discuss how soon after the surgery a DNR order will be reinstated.
Can a DNR order be revoked?
Yes. An individual or authorized decision maker may cancel a DNR order at any time by notifying the attending physician, who is then required to remove the order from their medical record.
What is a non-hospital DNR order?
Unlike a medical facility DNR order, a non-hospital DNR order is written for someone who wishes to refuse CPR and is outside a healthcare facility, such as at home or in a residential care setting. A non-hospital DNR order, also known as a pre-hospital DNR order, directs any emergency medical care providers, including any emergency medical technicians, paramedics, or emergency department physicians, to withhold CPR. These orders must also be signed by a physician, and are generally written on an official form, but depending on the state, they can also be on a bracelet, necklace, or wallet card. Although a non-hospital DNR order will be honored by emergency medical providers, they are not binding on any bystanders who may provide resuscitative actions.
Why is a non-hospital DNR order necessary?
Because a medical emergency requires an immediate response, emergency medical service (EMS) personnel are trained to act quickly in order to save lives. Thus, when they are called to a scene, they will do everything needed stabilize the individual and transport them to the nearest hospital, which includes administering CPR when necessary. If a person at home does not want CPR administered to them, they must obtain a non-hospital DNR order. Without such an order, EMS training dictates that they will administer CPR if a person undergoes cardiac or respiratory arrest. However, it is important to remember than a person can choose to refuse any medical treatment, including emergency care, so long as they have decision making capacity.
Does state law also govern non-hospital DNR orders?
Yes. Many states also have laws in place that govern non-hospital DNR orders. With the increase in popularity of hospice care and more and more people wanting to spend their last days in their home, there is an increasing need to prevent unwanted medical care from being administered. Non-hospital DNR laws allow qualified individuals the ability to refuse emergency resuscitative actions under certain conditions. You should check with your state’s Department of Health as well as your county’s EMS agency to determine if any statewide policies or local protocols exist governing non-hospital DNR orders.
Who should consider obtaining a non-hospital DNR order?
A non-hospital DNR order is intended for a seriously ill individual who has chosen to pass on in comfort of their home. Depending on the relevant state laws or policies, there may be restrictions on who can qualify for a non-hospital DNR order. Remember that a non-hospital DNR order must still be signed by a physician to be valid.
Can a non-hospital DNR order be revoked?
Yes. The individual or their authorized decision maker is able to cancel a non-hospital DNR order at any time by notifying the physician who signed the order and destroying the form and bracelet, wallet card, etc.
What happens when someone with a non-hospital DNR order is taken to the hospital?
If the individual is admitted to the hospital for any reason, it is important that the non-hospital DNR order accompanies them. If EMS personnel are present, they should take the DNR order with them on the ambulance, but it is still advisable for a family member to bring a copy of the DNR order with them. Although the admitting physician will usually write a new DNR order for the individual at the hospital, it is important that family member ensure that a facility DNR order is in place. Sometimes hospital personnel are unfamiliar with DNR laws or policies, and thus in an emergency important papers can occasionally be overlooked.