Almost everyone has heard of a do not resuscitate (DNR) order; it's the order for healthcare providers not to perform CPR on a victim of cardiac arrest. DNR orders are unique in medicine, making CPR the only medical intervention that requires an order not to administer it.
DNR orders come from physicians, not from patients. If a patient wants CPR to be withheld, he or she has to discuss the decision with a physician to get the order written. There are different end-of-life documents that cover a patient's wishes, called advance directives. Durable powers of attorney allow others to make decisions for an incapacitated patient, usually within guidelines outlined in the document.
Like other complicated medical care in the United States, application of DNR orders varies from state to state, especially regarding out-of-hospital (ambulance) care. Some states have standardized forms for DNR orders; if the order is not written on that specific form, it cannot be honored. Other states are less regimented, honoring any type of DNR order.
DNR Order RulesMany states allow emergency responders to follow DNR orders written to other care providers, even if they aren't written on standardized forms. For instance, paramedics and emergency medical technicians are usually allowed to follow DNR orders written for the staff of a nursing home. They may also be able to honor orders written for patients getting nursing care at home, if the home-care nurse has a DNR order. Each state is different, and municipalities may different within each state.
Regardless of the format, DNR orders almost always follow the same general rules to be valid:
- DNR orders must be written by physicians rather than verbalized. There are exceptions to this rule, such as an emergency medical service physician ordering an ambulance crew to withhold resuscitation via the radio or a registered nurse taking an order from an admitting doctor over the phone. Generally, there are safeguards for these exceptions to make sure the order is validated later.
- Written DNR orders must include the patient's name. It seems silly, but medications and other procedures are often administered to the wrong patients; following this order with the wrong patient would be disastrous.
- DNR orders must be dated. Depending on the state, orders may expire after a certain amount of time or there may be a deadline for the physician to follow-up. Even if a DNR order doesn't expire, a particularly old order may prompt caregivers to revisit the decision with patients.
- The DNR order must be signed by the physician. In those cases where orders were taken by a nurse over the phone, states usually set a deadline for the doctor to physically verify and sign the order - California, for example, sets 24 hours.
Making a DNR Order Work for YouIf you or a loved one has a DNR order and you want the order to be honored outside of the hospital, keep the physical order on hand and display it very conspicuously wherever rescuers might find you (or the patient). Make a point of telling rescuers when they arrive. It's a good idea to have more than one copy available and displayed.
If you are travelling, ask your travelling partners to have a copy of your DNR order on them at all times. Keeping a copy on the patient isn't always helpful to rescuers, who are likely to immediately remove a patient's clothing and are very unlikely to look in a wallet or purse.
Some sort of identification jewelry may be helpful. MedicAlert Foundation provides jewelry designed specifically for patients with DNR orders. The foundation keeps a copy of the order on file, and are capable of faxing it anywhere in the world. MedicAlert's jewelry contains a toll-free phone number rescuers can call to request the copy.
Hospice programs usually require DNR orders as a condition of participation. In those cases, calling an ambulance may not be necessary. Contact your hospice provider and ask about the procedure to follow when someone dies.
Ethical Complications of DNR OrdersIt's important to remember that a DNR order is not an order not to treat a patient, but simply an order not to resuscitate a patient. Again, depending on the location, healthcare providers may or may not provide other treatment for patients with a DNR order. Some doctors only withhold chest compressions while still providing advanced care like mechanical ventilation - at least until there is no longer a pulse. Other physicians will withhold any advanced treatments from a patient with a DNR order.
The inconsistent application of DNR orders means some patients get less than optimal care once providers are aware of the presence of a DNR order. There still needs to be more study on this issue, but some healthcare providers will even disregard basic care to patients with DNR orders.
Because of these issues, for anything other than a terminal diagnosis - like cancer or some end-stage chronic conditions - getting a DNR order may not be the right decision. Discuss the options with your physician now rather than later, but don't feel pressured to make up your mind about end-of-life decisions. Keep in mind that if we're just talking about withholding CPR, it may be better to let rescuers attempt resuscitation during an emergency. There is little chance that CPR out of the hospital will be successful anyway, and the ethical dilemma will be avoided.
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