Table of Contents
- Basics of Do-Not-Resuscitate Orders
- Elements of a DNR Order
- Arranging a DNR Order
- Common Types of DNR Orders
- Variations on General DNR Orders
- Consequences of Ignoring a DNR Order
- An Important Conversation
Whether you’re a medical professional or just a fan of TV medical dramas, you’ve likely heard the term “DNR order.” A do-not-resuscitate, or DNR, order is a patient’s order to not be resuscitated in the event that life-saving measures are required to treat cardiac and respiratory arrest.
While DNR orders have very real consequences for medical professionals who must follow their patient’s wishes, this important document can place a patient in control of their own well-being and allow them to make decisions that align with their overall treatment wishes.
Here’s everything you need to know about DNR orders, the various types, and when you do not resuscitate versus when you do.
Basics of Do-Not-Resuscitate Orders
An order to “do not resuscitate” is exactly what it sounds like: a legally binding document of a patient’s treatment wishes dictating that you do not resuscitate him or her in regard to the level of life-saving measures they’re willing to undertake to sustain life.
Many people incorrectly attribute a DNR order to mean that an individual has made the decision to refuse any additional medical treatment for a condition or diagnosis. This is a vast overgeneralization of what a DNR order actually stands for, because a patient’s agency to not want further medical treatment doesn’t necessarily coincide with a DNR order.
Note that a DNR order is specific to the state in which it’s signed, and each state has specific situations in which additional medical care can supersede the patient’s wishes — for example, if the patient is known to be pregnant. If a person were to move to a new state, he or she would need to arrange a new DNR order in the new state.
In most cases, one copy of the properly completed form is filed with the healthcare provider and one copy will stay with the patient. Many people will elect for a medical alert bracelet or wallet-sized card notifying potential first responders of their request to not be resuscitated, so be mindful to place this information in a conspicuous location. Rescuers should know the policies and laws for whether a bracelet or wallet card can suffice as a valid DNR order.
Elements of a DNR Order
The elements of a DNR order are like rules for healthcare providers. Each element is used to align the patient’s care with their values and preferences. A DNR order’s elements are chosen carefully to ensure clarity, legality, and alignment with the patient’s wishes.
Here are the key elements and why they’re important:
- Patient Consent. The decision to establish a DNR order must be made by the patient or their legally authorized representative, without any coercion. The patient or representative must fully understand the implications of the DNR order, including what it means for their care and the potential outcomes of not receiving CPR.
- Medical Evaluation. A thorough evaluation of the patient’s condition, including prognosis, overall health status, and quality of life, may be used to help determine if a DNR order is appropriate. A healthcare provider, typically a physician, will provide a recommendation based on the medical assessment results.
- Legal Documentation. The DNR order must be documented in the patient’s medical record, including specific details such as the patient’s name, the date, and the physician’s signature. The order must follow any specific forms or legal requirements mandated by the state or country to be considered valid.
- Clear Communication. All healthcare team members, including doctors, nurses, and emergency responders, must be informed about the DNR order. Ongoing discussions with the patient and their family are essential to ensure everyone understands the patient’s wishes and the implications of the DNR order.
- Scope and Limitations. The DNR order should clearly specify which interventions are covered. This generally focuses on CPR but potentially includes other life-sustaining measures, although, typically, other measures would be found in the patient’s advance directives. The DNR order should also be reviewed periodically, especially if the patient’s condition changes. It can be revoked at any time, in any way, by the patient or their representative.
- Ethical and Cultural Considerations. The patient’s right to make their own healthcare decisions must be supported and respected throughout the process. Cultural, religious, and personal values should be taken into account to ensure that the patient’s preferences and values are fully respected. Often a patient does not need a physician for this, just the correct legal form, completely filled out.
From obtaining clear consent to documenting discussions and ensuring revocability, these components work together to uphold ethical medical practice and honor a patient’s right to make decisions about their end-of-life care.
Dive into our insightful infographic for a clear breakdown of these crucial DNR elements so you can better understand how to honor a patient’s medical-care wishes.
Arranging a DNR Order
To arrange a do-not-resuscitate order, a person would typically need to reach out to their primary healthcare provider. At times, a provider may ask a person about their wishes around life-saving measures, but individuals can also initiate the conversation.
In each state, specific individuals’ signatures and input are required on paperwork for the DNR order to be valid.
Examples of required signatures can be seen on the paperwork required for an OOH-DNR (out-of-hospital do-not-resuscitate) order in Texas. This order must be signed by:
- A qualified physician. This person must be a licensed medical practitioner in the state in which care is being given and be assigned to or selected by the person seeking the DNR order. While this may seem like a given, a valid medical license to practice medicine could be a conflict for those who practice homeopathic medicine.
- A qualified relative. This person — generally a spouse, an adult child of the patient, or the patient’s next of kin — is often involved in the arrangement of a DNR order in the case where a patient is unconscious or otherwise unable to make decisions on their own behalf.
- A qualified witness. When more than one witness is required on the DNR paperwork, the second witness must be an objective third party not already named on the form (i.e., the physician) or the patient’s spouse or blood relative. Additionally, this person cannot currently or in the future benefit from the patient’s estate.
In most states, a social worker or other professional staff member can be a great resource to a person who wants to establish a DNR order or has specific questions about the requirements to arrange a DNR order.
Common Types of DNR Orders
While each state has its own unique paperwork that is appropriate for citizens of that state, there are two general types of DNR orders that are most common across the country: do not resuscitate in hospital and do not resuscitate out of hospital.
In-Hospital
When a person is admitted to a hospital, they will speak with admissions staff about their treatment plans and give consent to treatment. At this time, the patient can speak with their physician about their wishes to be resuscitated, to only use ventilation, or both. This discussion is important to the patient’s wishes being honored.
Do not resuscitate in hospital generally only applies to the length of a single hospital stay and must be reaffirmed with each visit. The temporary nature is meant to allow patients who are in changing health conditions to make decisions that are appropriate for their current situation but allow for built-in updates should their health outlook change.
Out-of-Hospital
Out-of-hospital DNR orders don’t simply mean “do not resuscitate” outside the hospital. Rather, they extend beyond the boundaries of a healthcare facility and are usually initiated by those who have a terminal illness or are in hospice care.
Some people who may believe that receiving CPR would harm them or otherwise leave them in a worse state may also decide to speak with their healthcare providers about arranging DNR paperwork.
Gain insight into the realities of CPR and its role in emergency situations by clicking play on the video below:
DNR Versus Do Not Treat
A DNR order indicates a patient’s preference not to receive CPR if they stop breathing and their heart stops beating, ensuring medical professionals won’t attempt life-saving measures like chest compressions or electric shocks.
This decision is typically made in advance based on the patient’s wishes and medical condition, allowing for clear medical guidance during emergencies.
Alternatively, Do Not Treat, or advance directives, is a broader directive encompassing more than just CPR. Surgeries, medications, or other treatments are also included in this order. For example, a cancer patient may refuse chemotherapy.
The decision not to treat, which can be made at any time, is based on the patient’s goals of care, quality of life considerations, and treatment preferences.
Variations on General DNR Orders
Your state may have the above-mentioned types of DNR orders or some variation of the two. Every state outlines its own situations in which medical providers do or do not resuscitate victims in need of medical intervention. It’s important to know the laws and approved forms that are recognized within your state.
Ohio, for example, distinguishes between two DNR variations: Do Not Resuscitate Comfort Care (DNRCC) and Do Not Resuscitate Comfort Care-Arrest (DNRCC-Arrest).
DNR Comfort Care
A DNRCC order requires that a person receive any care that eases pain and suffering but no emergency measure to resuscitate or sustain life. This type of DNR order is generally regarded as the better option for patients with a terminal illness, with a short life expectancy, or who may not be well enough to survive CPR without experiencing more medical complications.
DNRCC forms become effective the moment they are discussed with and signed off on by the person’s healthcare provider. However, in some states, such as Ohio, a power of attorney can supercede a DNRCC, so it’s important to discuss the patient’s wishes and potential implications with a person’s immediate family, next of kin, or power of attorney.
DNR Comfort Care-Arrest
A DNRCC-Arrest dictates that a patient receive standard medical care up to the time they experience a cardiac or respiratory arrest. This type of order does not go into effect until the time of cardiac or respiratory arrest, which is different from the more generalized and standing order of the DNRCC variation.
DNRCC-Arrest is only acceptable within the confines of the healthcare facility where the medical record is maintained. If the patient is sent home or needs to move to another facility for further treatment and the patient, or their power of attorney, elects to continue the DNR status, a new state of Ohio DNR order form must be completed for the patient, unless the patient has the state-approved DNRCC-Arrest form already filled out in its entirety.
Consequences of Ignoring a DNR Order
The process and guidelines for establishing a DNR order can vary by state. That said, should a medical professional or other emergency responder willingly ignore or dismiss a valid DNR order, the consequences can be significant, resulting not only in legal fees and insurance settlements but also in an emotionally charged and often very public experience.
Medical professionals must consider both patient wishes and applicable laws on life-sustaining decisions.
In cases where a patient does express their wishes to arrange a DNR order but his or her physician is unwilling to honor this ethical and legal commitment to the patient’s wishes, the physician has an obligation to arrange for or help otherwise facilitate the transfer of care of the patient to another licensed practitioner.
For EMS and other first responders, the nature of their work leaves them generally unaware of the person’s advance directives and whether there is an existing DNR order. This can present a complication in their role to step in and provide a quick response to an emergency situation.
As such, first responders must remain vigilant when assessing a patient for care and make sure to check for identification or indications of a standing DNR order.
This helps protect and honor the patient’s wishes, as well as the mental well-being of the responder who may otherwise have to withdraw life-saving measures after beginning care.
An Important Conversation
“Do not resuscitate” is an order that requires open and honest communication when being considered by a patient and his or her family. Being open with healthcare providers and with the patient’s family can help the entire treatment team and support network be on the same page about a person’s wishes for life-saving measures.
There are so many different considerations when it comes to DNR orders. The request that first responders “do not resuscitate” a person who stops breathing or enters cardiac arrest can be a confusing and difficult decision for their loved ones to understand — especially if they’re finding out from a healthcare provider at the height of an emergency.
By conducting research and speaking with professionals who can answer your and your family members’ questions, you can make the most informed decisions for all your healthcare and treatment needs.
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