A Do Not Resuscitate (DNR) order is a formal medical instruction written by a healthcare provider that directs the medical team not to attempt cardiopulmonary resuscitation (CPR) if a patient’s heart stops beating or their breathing ceases. This order recognizes patient autonomy, allowing an individual to choose to withhold an aggressive medical intervention at the end of life. If a patient experiences cardiac or respiratory arrest, the standard emergency procedure of attempting revival will not be initiated. This decision is part of broader advance care planning, which ensures that a patient’s wishes are respected during a medical crisis when they may be unable to communicate.
What Procedures Are Withheld by a DNR Order
A DNR order specifically targets cardiopulmonary resuscitation (CPR), which is a sequence of invasive interventions used to restore circulation and breathing following cardiac or respiratory arrest. These procedures include chest compressions, which are forceful pressures on the chest cavity designed to manually pump blood through the body. The order also withholds advanced airway management, such as intubation, where a tube is inserted into the windpipe to connect the patient to a mechanical ventilator. Furthermore, a DNR prevents the use of a defibrillator, which delivers an electric shock to the heart to restore a normal rhythm. These efforts can be physically demanding and often result in injuries, particularly in older or frail patients.
A DNR order is narrowly focused and does not equate to “do not treat” all other medical conditions. Patients with a DNR order continue to receive all other appropriate medical care, including pain management, antibiotics for infections, nutrition, and treatments designed to manage their illness and provide comfort. The order only comes into effect if the patient’s heart or breathing stops, and it does not affect the care provided before that specific event.
The Process of Deciding on DNR Status
The decision to establish a DNR order should ideally be made through a comprehensive discussion between the patient and their physician long before a medical crisis occurs. This conversation centers on patient capacity, which is the individual’s ability to understand the nature and consequences of CPR, including its low success rates and potential for harm. The physician provides a realistic prognosis and explains the likely outcomes of resuscitation given the patient’s underlying health conditions.
If a patient lacks the capacity to make an informed decision, a designated surrogate decision-maker is legally authorized to speak on their behalf. This surrogate, often a family member or a person named in a Durable Power of Attorney for Health Care, must make a decision based on the patient’s known values and wishes, a principle known as substituted judgment. If the patient’s wishes are unknown, the surrogate must decide based on the patient’s best interest, considering the medical futility of resuscitation.
The physician is ethically bound to respect patient autonomy and the decisions made by a legally appointed surrogate. Authorizing a DNR order is a complex, emotionally charged decision that requires good communication and support from the healthcare team throughout the deliberative process.
Distinguishing DNR from Other Advance Directives
The DNR order is often confused with other documents that fall under the umbrella of advance care planning, but it serves a distinct and specific purpose. A Living Will is a broader legal document that outlines a patient’s preferences for life-sustaining treatments, such as mechanical ventilation or artificial feeding, should they become terminally ill or permanently unconscious. Unlike a DNR, a Living Will is a statement of intent that guides future care, but it is generally not an immediate, actionable medical order.
The Physician Orders for Life-Sustaining Treatment (POLST), or Medical Orders for Life-Sustaining Treatment (MOLST) in some states, functions as an actual medical order, similar to a prescription. This form is designed for patients with serious illnesses or advanced frailty and is immediately actionable across various care settings, including the home. A POLST is more comprehensive than a DNR because it covers a wider range of treatment decisions beyond just the refusal of CPR, such as the use of intubation, feeding tubes, and the desired level of medical intervention.
While a DNR is a stand-alone instruction specifically about withholding CPR following cardiac or respiratory arrest, a POLST provides specific instructions for various life-sustaining treatments while the patient still has a pulse and is breathing. A POLST form often incorporates a DNR instruction as one of its possible options for resuscitation.
Implementing and Revoking the Order
For a DNR order to be effective, it must be officially documented, signed by the patient or their legal surrogate, and entered into the medical record by a physician. In a hospital setting, this is known as an in-hospital DNR, or sometimes a “no code” order, which is binding only within that facility.
For individuals outside a healthcare facility, an Out-of-Hospital DNR (OOH-DNR) is necessary. This is a state-specific form recognized by emergency medical services (EMS) personnel, ensuring that paramedics do not attempt resuscitation in the field. To be valid, the OOH-DNR form, bracelet, or necklace must be readily available for EMS to identify and honor the patient’s wishes.
The decision to have a DNR is not permanent, and the patient maintains the right to revoke or change the order at any time. Revocation is accomplished simply by informing the attending physician, or the surrogate can do so if the patient lacks capacity. Once the decision is made to revoke, the physician must remove the order from the medical record to prevent confusion during a future emergency.