End-of-life planning involves complex medical and legal decisions, often leading to confusion regarding terminology. Two frequently misunderstood terms are hospice care and the Do Not Resuscitate (DNR) order. Understanding the distinct purpose of each concept is important for patients and families making informed choices. This article clarifies the relationship between electing hospice services and establishing a DNR status.
Understanding Hospice Care
Hospice care is a specialized approach focused on providing comfort and support for individuals nearing the end of life. This philosophy of care, known as palliative care, prioritizes symptom management, pain relief, and emotional and spiritual support over treatments intended to cure the underlying disease. Eligibility for hospice requires a physician to certify that the patient has a prognosis of six months or less if their illness follows its expected course.
The goal of hospice is to enhance the patient’s remaining quality of life. Support is delivered by an interdisciplinary team that includes nurses, physicians, social workers, chaplains, and home health aides. These team members address the physical, emotional, and spiritual needs of the patient and provide education and 24-hour support for caregivers.
Hospice services are covered by the Medicare Hospice Benefit, provided the patient chooses to forgo aggressive curative treatments for the terminal illness. Patients can continue receiving hospice care beyond the initial six-month period if a hospice physician recertifies that they still meet the eligibility criteria. While under hospice care, patients can still receive curative treatments for conditions unrelated to their terminal diagnosis.
Understanding Do Not Resuscitate Orders
A Do Not Resuscitate (DNR) order is a specific medical instruction written by a physician and recorded in the patient’s chart. This order tells healthcare providers not to perform Cardiopulmonary Resuscitation (CPR) if the patient’s breathing or heart stops. Resuscitation attempts involve invasive procedures such as forceful chest compressions, artificial ventilation, intubation, and the use of a defibrillator.
The DNR is a narrowly focused document that applies only to specific life-saving procedures. It is established to permit a natural death, acknowledging that CPR is unlikely to be successful for these patients and may only prolong suffering. DNR status does not mean “Do Not Treat,” and a patient with this order continues to receive full medical attention for comfort, pain management, and other non-resuscitation treatments.
DNR orders can be established in hospitals, but state-specific forms are often required for use in other settings, such as a private home or long-term care facility. These out-of-hospital DNR documents, which may be called POLST or MOLST, are designed to be immediately recognizable and actionable by emergency medical services personnel. The patient maintains the autonomy to revoke or change a DNR order at any time.
Why Hospice Does Not Require a DNR
A patient is not legally or medically required to have a Do Not Resuscitate order to be admitted into hospice care. The decision to elect hospice and the decision to sign a DNR are two distinct choices, even though they often align in practice. Hospice enrollment is based on a prognosis and a choice of palliative care, while a DNR limits a single, specific medical intervention.
The fundamental difference lies in their scope: hospice is a comprehensive philosophy of comfort, whereas a DNR is a specific medical instruction. Most individuals entering hospice choose a DNR because the aggressive nature and low success rate of CPR conflict with the goal of comfort. For patients with advanced illnesses, successful resuscitation is unlikely and often leads to complications like broken ribs or prolonged time in an intensive care unit.
Despite the common choice, a patient can choose to maintain “full code” status, requesting that medical personnel attempt CPR if their heart stops while still receiving hospice services. This choice is respected as part of patient autonomy. The hospice team will ensure the patient understands the statistical reality of CPR outcomes given their advanced illness.
Other Important End-of-Life Planning Documents
While the DNR focuses on resuscitation, broader end-of-life planning involves several other legal documents known collectively as an Advance Directive. This directive communicates a person’s wishes regarding medical treatment should they become unable to speak or make decisions for themselves. Having these documents in place ensures that personal healthcare values guide future medical care.
One component is the Living Will, which outlines specific preferences for life-sustaining treatments such as mechanical ventilation, artificial nutrition, and hydration. This applies if a person has a terminal condition or is permanently unconscious. This document guides medical teams and family members concerning the patient’s desired level of intervention in end-of-life scenarios.
Another important document is the Durable Power of Attorney for Healthcare, often referred to as a Health Care Proxy or Agent. This form designates a trusted individual to make medical decisions on the patient’s behalf when they lack the capacity to do so. This designated person acts as the voice of the patient, ensuring their pre-expressed wishes are followed based on the current medical situation.