A Do Not Resuscitate (DNR) order is a specialized medical instruction reflecting a patient’s preference to forgo life-saving measures in the event of cardiac or respiratory arrest. This physician-signed order is a formal component of advance care planning, ensuring a patient’s autonomy in making decisions about their medical treatment. The existence of a DNR order represents an informed choice to prioritize a natural death over aggressive medical intervention when the heart or breathing stops. These directives communicate a patient’s wishes to the healthcare team, particularly if they become unable to speak for themselves during a medical crisis.
Defining the Scope of Resuscitation Orders
The term “resuscitation” within a DNR order refers to a predefined set of emergency procedures aimed at restarting the heart and breathing when they cease. The two procedures most commonly covered by a standard DNR order are Cardiopulmonary Resuscitation (CPR) and defibrillation. CPR involves chest compressions and artificial breathing, while defibrillation uses an electric shock to restore a normal heart rhythm. A DNR is not a general limitation on all medical care, but a specific directive that applies only during a cardiac or respiratory arrest. It is a medical order written by a physician and placed in the patient’s chart, based on the patient’s expressed wishes. This document ensures that healthcare providers do not intervene with these specific emergency measures.
DNR and the Exclusion of Mechanical Ventilation
In the setting of a cardiopulmonary arrest, a standard Do Not Resuscitate order is generally interpreted to include the refusal of intubation and mechanical ventilation. Intubation is the invasive procedure where a tube is inserted into the trachea to establish an open airway. This tube is connected to a mechanical ventilator, a machine that breathes for the patient.
The placement of a breathing tube is considered an integral part of aggressive attempts to restore life during a full code resuscitation. For patients with a DNR order, the refusal of CPR is understood to encompass the invasive interventions that follow, including the use of a ventilator. Healthcare providers presume that a patient who refuses chest compressions also refuses the subsequent step of being placed on life support. This signifies a wish to avoid the invasive nature of a full resuscitation attempt.
Intubation is typically prohibited during a cardiac or respiratory arrest under a DNR order. However, if a patient with a DNR is experiencing respiratory distress but has not yet suffered cardiac arrest, intubation may be medically appropriate unless specifically addressed. The general principle remains that a DNR order prevents the deployment of life-sustaining machinery, including mechanical ventilation, during a medical collapse.
Understanding DNI and Other Specific Life Support Directives
To address the specific issue of breathing support, a distinct directive known as a Do Not Intubate (DNI) order exists. A DNI order specifically instructs medical personnel to withhold the intubation procedure and subsequent mechanical ventilation, even if the patient stops breathing. This order can be separate from a DNR, allowing a patient to agree to chest compressions and defibrillation but refuse a breathing tube.
While a DNI is usually implied within the broader scope of a DNR, a separate DNI order allows for a more nuanced approach to care. Some patients choose a DNI to avoid the trauma and long-term implications of being on a ventilator, while still allowing other efforts if their heart stops. This option provides flexibility, though it is less common than the combined DNR/DNI status.
Beyond the binary choice of a full code or a DNR, comprehensive documents like Physician Orders for Life-Sustaining Treatment (POLST) or Medical Orders for Life-Sustaining Treatment (MOLST) offer a tiered approach. These forms allow patients to select specific interventions they want to receive or refuse, such as IV fluids, antibiotics, or non-invasive breathing support. These documents provide a detailed menu of options, moving beyond the simple “yes” or “no” of traditional DNR forms.
Ensuring Your Wishes Are Followed
The effectiveness of any advance directive, including a DNR, depends heavily on clear communication and documentation. Patients must have open conversations with their physician and family members about their goals of care and the specific procedures they wish to refuse. These discussions ensure that the medical order accurately reflects the patient’s values and preferences.
It is necessary to have legally valid documentation signed by the patient and the physician readily available. Advance directives like DNR or POLST forms are medical orders, and their portability between different care settings varies by state and institution. For example, a DNR order valid in a hospital may not automatically be honored by an ambulance crew or in a different state.
Portable medical order programs like POLST are designed to travel with the patient and be recognized across various settings, including the home, ambulance, and nursing facility. Patients and families must ensure that a copy of the final, signed order is placed prominently in the medical chart and transported with the patient during any transfer. Without clear documentation, there is a risk that a patient’s wishes may be overlooked during an emergency.