A non-resuscitation order (DNR) is a legally binding order signed by a doctor at the patient’s request. Its purpose is to let medical professionals know that if you have a sudden cardiac arrest or stop breathing, you do not want to be rescued.
People with chronic illnesses often see DNR as an elegant way to leave the world on their own terms. Details of DNR are usually discussed at admission, nursing facility, or hospice plan.
This article explains what resuscitation means, side effects, and survival. It also describes the rules that generally constitute a non-recovery order, how to make a DNR order work for you, and some ethical issues worth considering.
what recovery means
You may have watched hospital TV shows in which a patient in cardiac arrest is given cardiopulmonary resuscitation (CPR), comes back to life, and is back in shape right away. In fact, recovery is not that simple and inherently dangerous.
Procedures used to resuscitate someone include:
- Chest compressions: When a person’s heart stops beating, the heart cannot pump blood to the rest of the body, including the brain and lungs. Repeated chest compressions help keep blood flowing throughout your body until your heart returns.
- Intubation: When breathing is difficult or impossible due to illness or injury, a patient may be intubated. This involves inserting an endotracheal tube into the mouth and into the airway. The tube is then connected to the ventilator, which pushes air into the lungs.
- Cardioversion: Cardioversion is used to correct abnormal heart rhythms, including arrhythmias and atrial fibrillation (also called AFib). This can be done using a set of electrode pads to deliver electric shocks to the heart or with medication.
- IV Medications: Medications sometimes used for cardiac arrest include epinephrine, amiodarone, vasopressin, and atropine sulfate. These are “emergency cart drugs,” so named because they can be found on wheeled carts that medical professionals use during emergency resuscitation.
For patients with cardiac or respiratory arrest, the DNR states no These tactics will be used.
Respiratory and Cardiac Arrest
The difference between a respiratory arrest and a cardiac arrest is that the heart of a person in respiratory arrest is still beating, pushing blood throughout the body. Cardiac arrest patients do not. In both cases, however, the patient was unconscious and not breathing. Respiratory arrest invariably leads to cardiac arrest if no treatment is taken.
Resuscitation Side Effects
It’s important to realize that even if you have a successful resuscitation, you could suffer serious bodily harm as a result. For example, because the chest must be compressed deep enough to pump blood out of the heart, this can lead to broken ribs, perforated lungs, and possibly damage to the heart.
Those who are resuscitated may also suffer brain damage. This may be due to a lack of blood flow to the brain and then abnormal cell activity when blood flow to the brain is restored. In general, the longer the duration of CPR, the greater the risk.
How long does brain activity last after cardiac arrest?
These realities underscore the wisdom of considering your chances of actually surviving recovery. Survival statistics vary widely, in part because they involve many variables, including the patient’s age and health and whether CPR was performed in the hospital, where emergency support is available.
A 2021 review looked at studies published after 2008, focusing on CPR outcomes after in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA) in patients 70 years and older. The survival rates were 28.5% and 11.1%, respectively.
Meanwhile, a Danish study found that nursing home residents who received CPR after OHCA had a 30-day survival rate of only 7.7%
Ironically, most cardiac arrest patients are not in hospitals, nursing facilities, or hospice programs. About 70% of them were at home, and the vast majority (about 90%) died. CPR can double or triple a person’s chances of survival.
DNR commands are sometimes referred to by other names, although the command to not resuscitate someone is the same. Two other names for these orders are:
- No code: In hospitals, orders to suspend resuscitation are sometimes referred to as “no code” to distinguish it from “full code” or “code blue”, both of which mean that every effort should be made to treat patients recovery.
- Allow natural death (AND) commands: While the DNR command simply states that no attempt should be made to restart breathing or restart the heart if it stops, the AND command ensures that only consolation measures are taken. This will include pausing or stopping resuscitation, artificial feeding, fluids and other measures that prolong natural death. These orders are often used for terminally ill patients in hospice or elsewhere.
matters for discussion
A study on DNR and AND concluded, “Healthcare providers should address the concept of natural death, provide comprehensive information, and help patients and families overcome barriers.”
DNR Order Rules
The application of DNR orders varies by state, especially with regard to out-of-hospital (ie, 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 regulated and respect any type of explicit DNR order.
Many states allow emergency responders to follow DNR orders written to other care providers even if they are not written on a standardized form. For example, in New York State, paramedics and emergency medical technicians are generally allowed to follow DNR orders written for nursing home workers. Home care nurses can also fulfill orders written for patients receiving care at home if they have a copy of the DNR order on hand. Every state is different, and the municipalities within each state may be different.
Regardless of form or location, DNR orders almost always follow some of the same general rules; they must do so to be valid. DNR orders must:
- Written by a doctor, not spoken. There are exceptions to this rule, such as emergency medical services doctors ordering ambulance crews to stop resuscitation over the radio, or registered nurses taking orders from admitting doctors over the phone. Usually, these exceptions have safeguards to ensure that the order is verified later.
- Signed by the doctor. Where nurses take orders over the phone, states often set deadlines for doctors to physically verify and sign orders.
- Include the patient’s name and date. Depending on the state, the order may expire after a certain amount of time, or there may be a deadline for a doctor to follow up. Even if the DNR order has not expired, a particularly old order may prompt the caregiver to reconsider the decision.
Doctors must be diligent
A physician should write a DNR order only in consultation with the patient (if possible), the patient’s designated representative, or the patient’s family.
Let DNR orders work for you
If you choose a DNR order, you can do the following to ensure your wishes are respected:
- Keep physical orders handy and display them anywhere a healthcare worker may find you. Be sure to tell them about the order when they arrive. It is best to prepare more than one copy and display it, and carry one with you to the hospital.
- If you are traveling, please have your travel partner keep a copy of your DNR order for them at all times.
- Consider wearing a piece of medical jewelry to remind others of your intentions. The MedicAlert Foundation offers jewelry designed specifically for patients with DNR orders. The Foundation keeps a copy of the order on file and can fax it anywhere in the world.
DNR means limit
DNR orders address CPR issues, but do not include instructions for other treatments, such as pain medication or nutrition.
Ethical Issues with DNR Orders
Inconsistent application of DNR orders means that some patients may receive suboptimal care once providers are aware of the existence of DNR orders. It is important to remember that a DNR order is not a detention order all treatment; this is the command not recovery.
Even the mere mention of “DNR” can generate a wide range of responses, many of which are emotional. While everyone remains calm and rational, discuss these options with your doctor and your family—hopefully the sooner the better.
Either way, a painful choice
DNR orders may not be the right choice for people with terminal illnesses such as terminal cancer, dementia, or a progressive chronic disease. Patients with poor prognosis who survive resuscitation attempts have a lower likelihood of survival and a higher risk of heart, lung and brain damage.
A no resuscitation order directs a healthcare provider not to perform cardiopulmonary resuscitation (CPR) if the patient’s breathing stops or the patient’s heart stops beating. It can also create a dilemma, but it’s worth considering, especially in the context of your health (or that of a loved one). Here’s why: CPR requires the heart to be compressed deep enough to pump blood out of the heart. Those who are resuscitated may also suffer brain damage. As a result, it can lead to broken ribs, perforated lungs, and possibly even heart damage. For the frail, these actions may be too much. If you’re wondering about DNR orders, it’s important to understand that orders vary by state. So, investigate your state’s rules before proceeding.
Understandably, it is often difficult for loved ones to talk about DNR orders for their loved ones. They often feel as if they are giving up on a loved one. That’s why it’s wise to take charge of your end-of-life planning while you’re still able to. Being proactive also gives you time to investigate your state’s DNR order rules. Remember, however, that even if you receive a DNR order, you have the right to change your mind, revoke the order, and request CPR.
Frequently Asked Questions
How do I get a no resuscitation order?
You can get one from a hospital, nursing home, or hospice plan. Most states have standard forms that you can download online.
Who can sign a no resuscitation order?
The doctor must sign the DNR order with the consent of the patient or the patient’s medical representative.