Advance care planning allows individuals to define the scope of medical interventions they wish to receive, particularly toward the end of life. These discussions result in formal medical orders that guide healthcare providers when a person is unable to speak for themselves. A Do Not Resuscitate (DNR) order instructs medical personnel to withhold cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. The DNR-Comfort Care Arrest (DNR-CCA) is a specific version of this order, designed to balance aggressive care with the patient’s desire to avoid resuscitation.
Defining the DNR-CCA Order
The DNR-CCA designation is a physician’s order that limits life-sustaining treatment only after the patient’s heart or breathing has stopped. This order dictates a hard stop to aggressive measures upon the occurrence of cardiac or respiratory arrest. The “Arrest” component is the definitive trigger, signaling the moment the medical team must switch from a treatment-focused approach to a comfort-focused one.
Procedures withheld under a DNR-CCA order include the entire spectrum of Cardiopulmonary Resuscitation (CPR). Medical personnel will not administer chest compressions, insert an artificial airway for mechanical ventilation, or use a defibrillator to shock the heart. The order also prohibits the use of resuscitative drugs, such as epinephrine, which are part of advanced cardiac life support protocols.
The order ensures that the patient’s wishes to avoid invasive resuscitation are honored by all healthcare providers, including emergency medical services (EMS) personnel. This standardized approach prevents the initiation of procedures that are often physically traumatic for individuals with serious underlying health conditions. The DNR-CCA order provides a clear, actionable directive for emergency situations.
The Critical Distinction: Comfort Care vs. Comfort Care Arrest
The difference between the DNR-Comfort Care (DNR-CC) and the DNR-Comfort Care Arrest (DNR-CCA) lies in the timing of the shift to comfort measures. Under a DNR-CC order, the DNR protocol is activated immediately, meaning only comfort measures are administered before, during, and after a cardiac or respiratory event. This choice prioritizes comfort and symptom management above all else, even for conditions that might otherwise be reversible.
In contrast, the DNR-CCA order allows for all medically appropriate, life-saving treatments to be provided up until the point of cardiac or respiratory arrest. For example, a patient with a DNR-CCA order can receive antibiotics for a severe infection, intravenous fluids for dehydration, or testing for a new medical problem. The full range of standard medical care is maintained to treat non-fatal conditions, maximizing the patient’s chance of recovery or stabilization.
The choice between the two orders reflects the patient’s goals of care and current health status. A patient with a terminal illness may choose DNR-CC to ensure the focus remains purely on pain and symptom relief. For patients with chronic, serious illnesses who still wish to receive maximal treatment for acute, non-fatal events, DNR-CCA allows for aggressive care right up to the moment their heart stops. The DNR-CCA order allows patients to receive extensive care without accepting resuscitation.
What Supportive Medical Care Remains Permitted
A common misunderstanding is that DNR orders equate to “do not treat.” This is inaccurate, as the DNR-CCA order specifically addresses only the event of cardiac or respiratory arrest. All other supportive medical care remains fully permitted and is provided. The underlying principle is that the focus shifts from attempting a cure to maintaining dignity and comfort.
A patient with a DNR-CCA order continues to receive comprehensive symptom management, which is a core component of comfort care. This includes administering pain medication and providing anti-nausea drugs to manage gastrointestinal symptoms. Medical teams ensure that shortness of breath is managed through oxygen administration or other appropriate interventions.
Routine medical care also continues, such as wound care, repositioning for comfort, and managing suctioning needs to clear the airway. Hydration and nutritional support are maintained when appropriate and contributing to comfort. This holistic approach guarantees that the patient receives attentive medical and emotional support until the end, even though resuscitation is withheld.
Establishing and Revoking the Order
Establishing a DNR-CCA order requires a formal process involving a medical professional and the patient or their authorized representative. Only a physician or a licensed independent practitioner, such as a certified nurse practitioner or clinical nurse specialist, can issue this medical order. The decision must result from a detailed discussion about the patient’s condition, the burdens of CPR, and the likely outcomes.
Once the decision is made, the order is documented in the medical record, often using a specific, state-approved form. To ensure the order is honored outside of a hospital setting, patients are provided with portable identification, such as a standardized DNR form, a wallet card, or a specialized bracelet or necklace. This identification allows emergency medical personnel to quickly identify the patient’s wishes.
The patient retains the right to revoke the DNR-CCA order at any time. Revocation can be done simply by a verbal request to a healthcare provider or by physically removing or destroying the DNR identification. If a patient is unable to communicate, their legally authorized representative, such as a healthcare power of attorney, may also revoke the order.