A do-not-resuscitate order (DNR) is a legally binding physician’s order stating that no steps will be taken to restart a patient’s heart or restore breathing if the patient experiences cardiac arrest or respiratory arrest. These steps typically involve cardiopulmonary resuscitation (CPR), which is not always successful and comes with risks, especially for individuals who are elderly or very ill. A DNR order may also be called a do-not-attempt-resuscitation (DNAR) order or allow-natural-death (AND) order.
Legal Documents for Advance Care Planning
Advance care planning is a crucial activity for competent people of all ages. This process helps to ensure that a person’s wishes for medical care are respected and followed, even if they lose the ability to communicate them.
The legal aspect of this process typically involves creating an advance directive that is composed of two parts. First, a person (known as the principal) drafts a durable medical power of attorney (POA). This document appoints a trusted individual (known as the surrogate, proxy or agent) to handle health care decisions for the principal in the event that they are unable to participate in their own care. Second, the person should draft a living will, which provides detailed information on treatment preferences for potential medical situations. Ideally, the agent who is granted POA uses the written instructions in the living will to guide any health care decisions they must make on the principal’s behalf. Unfortunately, some people fail to make one or both of these advance directives.
Medical Orders for Advance Care Planning
While a DNR is also legally valid, it differs from the advance directives explained above in that it is a medical order. A person may draft a living will to specify their treatment preferences in various hypothetical situations, but this document is not an immediately enforceable medical order. If an individual is incapacitated, then health care professionals and emergency responders will pursue all potentially life-sustaining treatments in the event of a medical crisis unless a valid order written by a physician (like a DNR) is presented.
Who Needs a Do-Not-Resuscitate Order?
Every competent person has the right to refuse even life-saving medical treatment. Appropriate advance care planning ensures this right even if an individual becomes unable to participate in their own care decisions. Yes, living wills and durable POAs for health care are important for people of any age to have, but not every person needs a DNR order.
Some people wish to limit the care they receive in foreseeable medical circumstances because they feel that extreme measures meant to prolong life may also negatively impact their quality of life. For example, health care professionals and first responders are trained to administer aggressive interventions like CPR to prevent death unless otherwise directed. However, the medical benefits of CPR are limited. This emergency procedure is only intended for use on healthy individuals, not the elderly or those with severe or terminal health conditions like widespread infections or cancer.
One study published in The Journal of the American Osteopathic Association found that most elders (81 percent) erroneously believed their chance of surviving inpatient CPR and being discharged from the hospital was 50 percent or better. While the odds of survival are dependent upon a patient’s unique situation, the study authors’ reviews of previous literature show that “...a mere 3% to 5% of patients are surviving CPR to discharge, and a survival rate of 0% has been reported.”
Sadly, even if CPR successfully resuscitates a very old or frail individual, it is possible that they may suffer broken bones, damage to the brain and other organs, and/or they may no longer be able to breathe without a ventilator. Because of the risks involved, DNR orders specifically address an infirm patient’s wish that doctors do not attempt CPR if their heart and/or breathing stops. Most people who obtain DNR orders are already in poor health and receiving treatment in the hospital or another health care facility.
The elderly and those with severe health conditions may speak with their physicians about the potential risks and benefits of CPR and ultimately decide that they do not wish to receive this intervention. Those with terminal illnesses may obtain a DNR order because they do not want to artificially delay the inevitable, opting instead for a more peaceful or natural death. Regardless of one’s reasons, DNR orders allow patients to continue to exercise control over their care even in emergencies.
How Does a DNR Order Work?
The decision to forego CPR and “full care” must be made by the patient themselves if they are competent to do so. If they are not competent, then their named surrogate decision maker or health care proxy must make this decision on their behalf. In either case, a care plan meeting with the patient’s physician(s) is highly recommended to thoroughly discuss all aspects of implementing or deciding against a DNR order.
If a patient obtains a DNR order, it is then placed in their hospital chart. It is important for the patient and/or their family members to remind medical staff about the DNR order, because the first action doctors and nurses will take if a patient’s heart or breathing stops is to attempt resuscitation. This is yet another reason why it is so important for family caregivers to be present and advocate for their loved ones, especially in hospitals and other acute care settings. However, if a patient is receiving hospice care, which focuses solely on symptom management rather than curative treatment for terminal patients, DNR orders are fully respected by the hospice staff and additional coaching and advocacy are usually not required.
It is important to understand that a DNR order only affects whether a patient will receive CPR. All other necessary treatments—including palliative care—should be continued unless the patient or their surrogate states otherwise. Regardless, it is still important to address how a DNR might affect other routine and life-sustaining treatments with a patient’s physician(s) to ensure their entire care team is on the same page.
Keep in mind that DNR orders are subject to ethical debate in uncommon yet plausible scenarios. Physicians must often make split-second decisions with huge implications in emergency and surgical scenarios. Regular deep and honest discussions among patients, advocates and physicians are the best method of avoiding undesirable health care outcomes. Social workers, attorneys, mental health professionals, clergy members and other trusted individuals can also provide guidance regarding resuscitation and end-of-life care decisions.
There are infinite contingencies that patients and doctors alike cannot specifically prepare for. Fortunately, another type of valid medical order for advance care planning has grown in popularity over recent years that provides more control for patients and more comprehensive guidance for medical professionals. A physician order for life-sustaining treatment (POLST) form is designed to provide a full set of medical orders that better represents a patient’s overall preferences for their medical care, such as ventilator use and artificial nutrition, rather than just the one decision regarding CPR.
Sources: Do-Not-Resuscitate (DNR) Orders (https://www.merckmanuals.com/home/fundamentals/legal-and-ethical-issues/do-not-resuscitate-dnr-orders); Advance Care Planning: Healthcare Directives (https://www.nia.nih.gov/health/advance-care-planning-healthcare-directives); How Misconceptions Among Elderly Patients Regarding Survival Outcomes of Inpatient Cardiopulmonary Resuscitation Affect Do-Not-Resuscitate Orders (https://jaoa.org/article.aspx?articleid=2093313); POLST & Advance Directives (https://polst.org/about/polst-and-advance-directives/)