A non-resuscitation order (DNR) is a legally binding order signed by a physician at the request of the patient. Its purpose is to inform healthcare providers that you do not want to resuscitate if you have sudden cardiac arrest or stop breathing. This is a common problem for the chronically ill and the elderly. The details of the DNR are generally discussed upon admission to a hospital, nursing facility, or hospice program.
What does resuscitation mean?
You may have seen TV shows set in hospitals where a cardiopulmonary resuscitation (CPR) patient receives cardiopulmonary resuscitation (CPR) and is brought back to life in the blink of an eye. In fact, resuscitation is not that easy and can be dangerous in itself.
Procedures used to resuscitate someone include:
- Chest constriction : When a person's heart stops beating, it cannot pump blood to the rest of the body, including the brain and lungs. Repeated pressure on the chest helps maintain blood flow throughout the body until the heart is restored.
- Intubation – When breathing becomes difficult or impossible due to illness or injury, the patient may be intubated. This involves inserting an endotracheal tube through the mouth into the airway. The tube is then connected to a ventilator, which forces air into the lungs.
- Cardioversion : Cardioversion is used to correct cardiac arrhythmias, including arrhythmias and atrial fibrillation. This can be done with a series of electric shocks to the heart or with medicine.
- Intravenous Medications : Medications sometimes used for cardiac arrest include epinephrine, amiodarone, vasopressin, and atropine sulfate.
Respiratory or cardiac arrest
The difference between respiratory arrest and cardiac arrest is that in patients with respiratory arrest, the heart continues to beat, pushing blood through the body. Patients with cardiac arrest do not. However, in both cases, the patient is unconscious and not breathing. Respiratory arrest always leads to cardiac arrest if nothing is done to treat it.
Side effects of resuscitation
It is important to understand that even if you are successfully resuscitated, you may suffer serious physical injury as a result. For example, because the chest must be compressed firmly and deeply enough to pump blood out of the heart, this can lead to rib fractures , lung punctures, and possibly heart damage.
Those who are resurrected can also suffer brain damage. This may be due to insufficient blood flow to the brain accompanied by abnormal cellular activity when blood flow to the brain is restored. Generally, the risk increases with the duration of CPR.
Survival rates in intensive care
Another important thing to think about when considering DNR is your chances of surviving in intensive care.
Survival statistics vary widely, in part because they include many variables, including the patient's age and health, whether or not CPR was performed in the hospital, and other factors.
The 2021 review looked at studies published since 2008 on CPR outcomes in patients aged 70 years or older after in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA). The survival rate was 28.5% and 11.1%, respectively.
Another Danish study found that the 30-day survival rate for nursing home residents who received CPR after OHCA was 7.7%.
Why DNR could be the right choice
DNR may be the right choice for people with a terminal illness such as advanced cancer, dementia, or a progressive chronic disease. Patients with a poor prognosis have a lower chance of survival and a higher risk of damage to the heart, lungs, and brain if they survive after attempting resuscitation.
Types of orders
The DNR order is sometimes known by other names, although the directive not to resuscitate someone is the same. Two other names for these orders:
- No code – In the hospital, a stop resuscitation order is sometimes called a "do not resuscitation order" to distinguish it from a "complete code" or "code blue" meaning that everything possible should be done during resuscitation .
- Allow Natural Death (Y) : While DNR simply indicates that you should not attempt to restart breathing or restart the heart if it stops, the Y command ensures that only comfort measures are taken. This may include stopping or terminating resuscitation, artificial feeding, fluids, and other measures that can prolong natural death. These orders are generally used in hospices or for hospice patients.
Rules for ordering DNR
As with other complex medical care in the United States, the application of DNR orders varies from state to state, especially with respect to out-of-hospital ( ambulance ) care. Some states have standardized forms for DNR orders; If the order is not registered in this specific form, it cannot be executed. Other states are less regulated and comply with DNR orders.
Many states allow emergency services to follow DNR orders written to other healthcare providers, even if they are not written on standard forms. For example, in New York State, paramedics and ambulance technicians can generally follow DNR orders written for nursing home staff. They can also follow written orders for patients receiving home nursing care if the home care nurse has a copy of the DNR order. Every state is different and municipalities can be different in each state.
Regardless of format or location, DNR orders almost always obey the same general rules to be valid:
- DNR orders must be written by doctors, not spoken. There are exceptions to this rule, such as an ambulance doctor who orders an ambulance to stop radio resuscitation, or a registered nurse who takes a doctor's order over the phone. Generally, there are safeguards for these exceptions to ensure that the order is confirmed at a later date.
- Written DNR orders must include the patient's name; placing a DNR order on the wrong patient would be a disaster.
- DNR orders must be dated. Depending on the state, orders may expire after a certain time, or the doctor may have a deadline for follow-up. Even if the DNR order does not expire, a particularly old order can cause guardians to reconsider the decision with patients.
- The DNR order must be signed by a physician. In cases where the nurse took the orders over the phone, states generally set a time frame within which the doctor must physically verify and sign the order.
Make DNR work for you
If you choose to order DNR, here is what you can do to make sure your wishes are met:
- Keep physical order handy and display it where paramedics can find you (or a patient). Tell them about your order upon arrival. It is a good idea to have and display more than one copy and also one copy to accompany the patient to the hospital.
- If you are traveling, ask your partners to carry a copy of their DNR order with them at all times. Keeping a copy with the patient does not always help rescuers, who are more likely to remove the patient's clothing immediately and are unlikely to look in their wallet or purse.
- Consider wearing medical jewelry . The MedicAlert Foundation provides jewelry specifically designed for patients with DNR orders. The Foundation maintains a copy of the order on file and can fax it anywhere in the world.
Ethical complications of DNR orders
Inconsistent use of DNR orders means that some patients may receive suboptimal care if providers find out about DNR.
It is important to remember that a DNR order is not an order to stop treating a patient, but simply an order not to resuscitate the patient.
Because of these issues, getting a DNR order can be the wrong decision for anything other than an incurable diagnosis, such as cancer or some end-stage chronic conditions. Discuss your options with your doctor now and not later, but don't give in to pressure to make end-of-life decisions.
Frequently asked questions
How to get a do not resuscitate order?
A resuscitation prohibition order can be obtained from a hospital, nursing home, or hospice. Most states have standard forms that you can download online.
Who can sign a resuscitation prohibition order?
The physician must sign the DNR order with the consent of the patient or the patient's trustee .
How to revoke a do not resuscitate order?
You can change your mind about the DNR order at any time by telling your doctor, nursing home staff, or a family member to remove it from your file.