In the medical setting, patients often make choices about their future care through advanced directives, which are instructions outlining preferences for medical treatment if they become incapacitated. Planning for end-of-life care ensures that medical interventions align with a person’s values and goals. A Do Not Resuscitate (DNR) order is a formal medical instruction created by a physician to prevent cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. This article clarifies the distinctions within DNR orders, specifically focusing on the designation known as Comfort Care Arrest (CCA).
Defining the Standard Do Not Resuscitate Order
A standard Do Not Resuscitate order, sometimes referred to as DNR-A or DNR-Full, is a directive placed in a patient’s medical record instructing healthcare providers to withhold specific life-saving procedures should the heart or breathing stop suddenly. The procedures withheld are known collectively as resuscitation efforts, which attempt to restart the heart and lungs. These interventions include chest compressions, artificial ventilation (intubation), and electric shocks (defibrillation or cardioversion) used to correct certain heart rhythms. Resuscitative drugs, like epinephrine or atropine, which stimulate the heart or raise blood pressure during an arrest, are also excluded from care. This order focuses solely on the absence of resuscitation attempts and does not prevent the patient from receiving other forms of ongoing medical treatment.
The Specifics of Comfort Care Arrest (CCA)
The Do Not Resuscitate-Comfort Care Arrest (DNR-CCA) order represents a tiered approach to end-of-life medical planning, offering a middle ground between full life-prolonging treatment and comfort measures only. The intent of DNR-CCA is to allow for aggressive medical intervention for all conditions up until the moment a person experiences cardiac or respiratory arrest. While the patient is alive, they can receive treatments like powerful blood pressure medications, antibiotics for an infection, or non-invasive respiratory support.
The CCA designation dictates that once the heart stops beating or breathing ceases, all efforts to resuscitate are immediately stopped, and the focus shifts exclusively to providing comfort care. This order contrasts sharply with a Do Not Resuscitate-Comfort Care (DNR-CC) or Comfort Care Only (DNR-CCO) designation, which restricts all life-prolonging treatments from the moment the order is written. Under a DNR-CC order, a patient would not receive interventions like certain intravenous fluids or tests designed to cure an illness, focusing instead on symptom management regardless of whether an arrest is imminent.
The DNR-CCA status is often chosen by patients who wish to fight their illness with all available medical tools but want to avoid the trauma and low success rate of CPR at the end of life. The specific terminology for this tiered system can vary between hospitals and state protocols, but the underlying difference—treatment up to arrest versus comfort care only—remains consistent. DNR-CCA allows for a full effort to sustain life and manage conditions until the body naturally reaches the point of cardiopulmonary arrest.
Treatments That Continue Under DNR Orders
A common misunderstanding is that a DNR order means healthcare providers will cease all care for the patient, which is inaccurate. The DNR order specifically addresses only the attempt to restart the heart and lungs after they have stopped. Regardless of the DNR status—whether standard DNR, CCA, or CC—patients continue to receive comprehensive medical treatments aimed at improving their quality of life and managing symptoms.
The focus remains on palliative care, which involves active measures to ensure the patient is free from pain and discomfort. Treatments such as pain management medications, including opioids like morphine, are continued and often increased to minimize suffering. Symptom control measures, including anti-nausea medications, anxiety-reducing agents, and supplemental oxygen to relieve shortness of breath, are always provided.
Basic nursing care, which includes hygiene, repositioning, and emotional support, is maintained. Hydration and nutrition, such as intravenous fluids, may be continued if they are necessary for comfort and are not being used as a life-prolonging measure. Continuing these treatments helps maintain the patient’s dignity and relieve distress throughout the dying process.
Establishing and Validating DNR Status
A DNR order, including the DNR-CCA designation, is a medical order and requires the signature of a physician or other licensed independent practitioner to be valid. This process begins with an informed discussion between the healthcare provider and the patient or their authorized surrogate decision-maker about the benefits and burdens of resuscitation. The order must reflect the patient’s wishes and goals of care, ensuring their autonomy in medical decision-making.
For patients outside of a hospital setting, such as at home or in a nursing facility, special documentation is required to ensure the order is honored by Emergency Medical Services (EMS) personnel. These are often referred to as out-of-hospital DNR orders or are incorporated into a standardized form called Physician Orders for Life-Sustaining Treatment (POLST). These pre-hospital forms are legally binding and often accompanied by a visually distinct item, such as a bracelet or necklace, for rapid identification by first responders.
The order must be clearly noted in the patient’s medical record and must travel with the patient if they move between care settings. Out-of-hospital DNR forms are typically required to be posted prominently or kept readily available to ensure that the patient’s preferences are followed consistently. A patient retains the right to revoke or change their DNR status at any time simply by informing their physician.