A Do Not Resuscitate (DNR) order is a formal medical instruction specifying that cardiopulmonary resuscitation (CPR) should not be performed if a person’s heart stops beating or they stop breathing. This order is a crucial part of end-of-life care planning, honoring a patient’s wishes regarding aggressive life-saving measures. A DNR is not always an absolute “all-or-nothing” decision. Medical practice recognizes variations or “levels” of the order, allowing for a nuanced approach that respects patient autonomy while still permitting other medical treatments. These variations acknowledge that a person may wish to avoid the trauma of CPR but still require other medical intervention.
Defining the Scope of Resuscitation
A standard, full resuscitation effort is initiated when a patient experiences cardiac or respiratory arrest and no DNR order is in place. This aggressive intervention includes a suite of procedures designed to restore circulation and breathing, primarily Cardiopulmonary Resuscitation (CPR), which involves forceful chest compressions to manually pump blood.
A full resuscitation code also involves advanced procedures. These include electrical defibrillation to shock the heart back into a viable rhythm and intubation, which places a tube into the trachea for mechanical ventilation. Specialized drugs, such as epinephrine, are administered intravenously to stimulate the heart and stabilize blood pressure, following protocols known as Advanced Cardiac Life Support (ACLS). A full DNR order specifically instructs healthcare providers to withhold all of these interventions in the event of an arrest.
Understanding Graduated DNR Orders
The concept of a graduated DNR addresses the need for patient choices that fall between full resuscitation and allowing natural death without medical aid. These limited or selective orders acknowledge that certain life-sustaining treatments may still be beneficial even if CPR is deemed inappropriate. These “levels” of DNR vary by institution and state, allowing patients to tailor their end-of-life care.
One common variation is the DNR Comfort Care Only (DNR CCO), sometimes referred to as Allow Natural Death (AND). Under this order, the focus shifts entirely to pain management and symptom control, such as administering oxygen and comfort medications. This level excludes all life-prolonging interventions, including CPR, intubation, and aggressive laboratory testing or antibiotic use intended only to extend life.
A different variation is the DNR with Limited Medical Interventions. This order permits a patient to refuse CPR and defibrillation but allows for other treatments that may stabilize them, such as intravenous fluids, specific antibiotics, or medications for blood pressure support. This selective approach provides an option for patients with chronic conditions who may benefit from limited stabilization measures but wish to avoid CPR. The goal is to provide treatment for reversible conditions without the commitment to full, invasive resuscitation.
The Distinction Between Settings and Documentation
The location where a medical event occurs influences how a DNR order is documented and executed. An In-Hospital DNR (I-DNR) is a physician’s order placed directly into a patient’s medical chart, valid only within that healthcare facility, such as a hospital or long-term care center. This chart-based order informs facility staff that they should not initiate a “code blue” or full resuscitation effort.
In contrast, an Out-of-Hospital DNR (OHDNR) is a state-mandated legal document required for emergency medical services (EMS) personnel to honor the DNR request in a non-clinical setting. Since EMS providers do not access a patient’s electronic medical record, this portable form must be present at the scene. Without this specific OHDNR form, EMS personnel are generally required by law to attempt full resuscitation.
OHDNR forms, or similar state-specific documents like Physician Orders for Life-Sustaining Treatment (POLST) or Medical Orders for Life-Sustaining Treatment (MOLST), document the graduated levels of care. These standardized documents often use a checklist format, allowing the patient and physician to specify exactly which life-sustaining treatments should be withheld or provided. The OHDNR translates nuanced DNR wishes into clear, actionable instructions for first responders.
Related End-of-Life Planning Concepts
The DNR order operates within a broader framework of end-of-life planning concepts. One related order is the Do Not Intubate (DNI), which is a more limited instruction than a full DNR. A DNI specifies the refusal of mechanical ventilation through a breathing tube but does not necessarily preclude other life-sustaining measures or chest compressions.
The distinction is important because a patient may stop breathing (respiratory arrest) but still have a pulse, where intubation might be attempted before the heart stops. A DNI allows the physician to treat the patient aggressively for reversible conditions, such as administering medication, while respecting the patient’s wish to avoid the ventilator. This differs from a DNR order, which is triggered by the full cessation of both breathing and heart function.
Both DNR and DNI orders are distinct from Advanced Directives (AD). These are legal documents, such as a Living Will, used to communicate a person’s wishes regarding medical treatment should they become unable to make decisions themselves. An Advanced Directive is a statement of preferences, not a direct medical order. The physician writes the DNR or DNI order on the patient’s chart or official form, often in response to the wishes expressed in the Advanced Directive.