End-of-life planning involves making complex decisions about future medical care. A Do Not Resuscitate (DNR) order is a recognized component of this planning, serving as a direct instruction to medical providers. This order addresses a narrow but significant aspect of care, ensuring an individual’s wishes regarding life-saving interventions are honored during a sudden medical crisis. Understanding the meaning, documentation, and scope of a DNR order is crucial for advance care planning.
Defining a Do Not Resuscitate Order
A Do Not Resuscitate (DNR) order is a specific medical instruction directing health care professionals to withhold cardiopulmonary resuscitation (CPR) if cardiac or respiratory arrest occurs. This order prevents procedures intended to restart the heart or breathing, which are invasive and often carry a low success rate for individuals with advanced illness. Procedures withheld include:
- Chest compressions
- Artificial ventilation
- Intubation
- Electrical shock (defibrillation)
A DNR order is not a “do not treat” order. The instruction focuses only on resuscitation efforts when the heart stops or breathing ceases. All other routine medical care continues, including diagnostic tests, surgery, administering antibiotics, and dialysis. Comfort measures and palliative care, which focuses on pain management and symptom relief, should always be provided.
The decision to establish a DNR order follows a thorough discussion with a physician about the likely outcomes of CPR. For patients facing terminal illness, aggressive resuscitation may only prolong the dying process or reduce the quality of life. The DNR allows for a natural death and is often related to legal forms like Physician Orders for Life-Sustaining Treatment (POLST) or Medical Orders for Life-Sustaining Treatment (MOLST).
Documentation, Consent, and Physician Involvement
For a DNR order to be valid, it must be documented in the patient’s medical record and requires a physician’s signature. The attending physician discusses the risks and benefits of resuscitation with the patient, obtains informed consent, and then writes the order. This process ensures the patient understands the scope and implications of the order.
Consent must come directly from the patient if they possess decision-making capacity. If the patient is incapacitated, the decision can be made by a legally authorized surrogate decision-maker, such as a health care agent or proxy. The surrogate is tasked with making decisions based on the patient’s known values and preferences. State laws govern the requirements for consent and documentation.
A DNR order is not permanent; the patient or their authorized proxy maintains the right to revoke or change the order at any time. Revocation can often be done by verbally informing a health care provider or by destroying the physical documentation. The health care team is then obligated to document the change and resume full resuscitation efforts.
Application of DNR Orders Outside of Hospital Settings
Providing emergency care outside of a medical facility requires an Out-of-Hospital DNR (OOH DNR) order. An in-hospital DNR is recorded in the facility’s chart and is not accessible to Emergency Medical Services (EMS) personnel responding to a home or public emergency. Therefore, a separate OOH DNR form is required to communicate the patient’s wishes to first responders.
OOH DNR forms are standardized, state-specific legal documents instructing pre-hospital providers to withhold resuscitative measures. Patients with an OOH DNR often wear a specialized identification device, such as a standardized bracelet or necklace, to make the instructions immediately visible. Without the proper OOH DNR documentation or identification, EMS personnel are typically required by protocol to initiate full resuscitation efforts.
DNR Orders and Other Advance Directives
The DNR order is frequently confused with other forms of advance care planning, but each document serves a distinct purpose. A DNR is a specific medical order concerning only cardiopulmonary resuscitation. It is a physician-signed instruction that directs the withholding of CPR in the event of cardiac or respiratory arrest.
A Living Will, or Health Care Declaration, is a broader legal document created by the patient. It outlines general wishes regarding life-sustaining treatments, such as artificial nutrition, hydration, and mechanical ventilation, if the patient becomes terminally ill or permanently unconscious. While a Living Will can express a desire to forgo CPR, it is not a medical order and may not be immediately actionable by health care providers without a physician’s certification of the patient’s condition.
The Health Care Proxy, or Medical Power of Attorney, names a specific person to make medical decisions on the patient’s behalf when the patient is unable to do so themselves. This proxy’s authority covers all medical decisions, including the decision to sign a DNR order or interpret the patient’s wishes outlined in a Living Will. These three documents work together to form a comprehensive plan, but they are not interchangeable, each addressing a different aspect of end-of-life care.