A common misconception is that a Do Not Resuscitate (DNR) order is mandatory for admission into hospice care. Many people assume these two concepts are inextricably linked, believing that electing for hospice automatically means forfeiting the right to life-sustaining measures. This belief often stems from a misunderstanding of both the legal requirements and the underlying philosophy of hospice treatment. Clarifying the relationship between a DNR and hospice is important for individuals making end-of-life decisions.
Defining Hospice Care and DNR Orders
Hospice care is a specialized form of interdisciplinary support for individuals with a terminal illness, typically defined as having a prognosis of six months or less if the disease runs its natural course. The entire focus of hospice shifts away from curative treatments aimed at reversing the illness toward maximizing the patient’s quality of life through pain and symptom management. The Medicare Hospice Benefit covers this care, providing comprehensive services like nursing, social work, and spiritual counseling in a variety of settings.
A Do Not Resuscitate (DNR) order, by contrast, is a specific medical instruction written by a physician. This order directs healthcare providers, including emergency medical technicians (EMTs), not to perform cardiopulmonary resuscitation (CPR) or other advanced cardiac life support measures if the patient’s heart stops or they stop breathing. Resuscitation attempts involve aggressive interventions like chest compressions, electrical shocks, and intubation, which are distinct from the comfort care hospice provides.
The Direct Answer: DNR Requirements for Hospice
The simple and direct answer is that a DNR order is not legally required for a patient to be admitted to a Medicare-certified hospice program. Federal guidelines, including those governing the Medicare Hospice Benefit, do not mandate a DNR status as an eligibility requirement for enrollment. A patient is allowed to maintain “full code” status, meaning they wish to receive full resuscitation measures.
However, the philosophy of hospice care makes the decision to forgo resuscitation highly recommended and often a practical necessity. Hospice accepts the natural progression of the disease, and aggressive interventions like CPR directly contradict this guiding principle. If a patient insists on full resuscitation, the hospice provider may require a modified DNR or, in rare cases, may refuse admission, as providing full-code care conflicts with the agency’s model of palliative treatment.
Comfort Care and Goals of Hospice Treatment
The distinction between comfort care and curative care is the central issue driving the DNR conversation within hospice. Comfort care, which is the foundation of hospice, focuses on palliative measures such as pain control, symptom relief, and emotional support to ensure dignity. This approach prioritizes the comfort and well-being of the patient over prolonging life at all costs.
Curative care, in contrast, involves aggressive treatments aimed at reversing a disease or extending life, which includes procedures like mechanical ventilation or extensive diagnostic testing. A cardiopulmonary arrest in a patient with a terminal illness is typically the final, natural event of their disease process. Attempting CPR, which is a life-extending measure, is often physically traumatic, leading to fractured ribs, punctured lungs, and poor neurological outcomes in this patient population.
Signing a DNR order aligns the patient’s wishes with the fundamental goals of hospice care. It prevents the sudden interruption of peaceful symptom management with painful, low-probability interventions like resuscitation. This choice ensures that the patient’s remaining time is spent in comfort, rather than subjecting them to medical procedures that conflict with the acceptance of a natural death.
Required Paperwork and Patient Autonomy
While a DNR is a medical order, it is part of a larger framework of legal documents known as Advance Directives. These broader documents, such as a Living Will or a Durable Power of Attorney for Health Care, allow individuals to communicate their healthcare preferences and designate a surrogate decision-maker if they become incapacitated. An Advance Directive covers a wide range of decisions beyond just CPR, including the use of feeding tubes or mechanical ventilators.
In the hospice setting, another document often used is the Physician Orders for Life-Sustaining Treatment, or POLST (sometimes called MOLST or POST, depending on the state). Unlike an Advance Directive, which is a legal document outlining general wishes, a POLST is a set of actionable, portable medical orders signed by a healthcare professional. The POLST form clearly outlines the patient’s specific treatment wishes, including their DNR status, and is honored by emergency medical services, providing an immediate guide for care.
Patient autonomy remains a paramount consideration in all end-of-life planning. The patient or their designated healthcare agent retains the right to revoke or change a DNR order or withdraw from hospice care at any time. Although hospice encourages a focus on comfort, the final decision regarding life-sustaining treatment rests with the individual, ensuring their wishes are respected throughout their care journey.