A Do Not Resuscitate (DNR) order is a medical directive instructing hospital staff to withhold cardiopulmonary resuscitation (CPR) and related interventions if a patient’s heart stops beating or they stop breathing. This order is placed in the patient’s medical chart to guide the healthcare team during a cardiac or respiratory arrest event. It specifically prohibits procedures like chest compressions, electrical defibrillation, and artificial ventilation. A DNR is an instruction regarding a very specific set of life-saving measures and does not constitute a withdrawal of all medical care.
Patients with a DNR order still receive all other appropriate medical treatments, such as pain control, antibiotics, comfort care, and oxygen therapy. The order is a focused decision to allow a natural death process instead of aggressive resuscitation attempts. Establishing, documenting, and implementing this order involves collaboration between the patient, their decision-makers, and the attending physician.
Establishing the Decision
The decision to establish a DNR order originates with the patient’s right to autonomy, meaning they hold the legal authority to choose or refuse medical treatment. Before the order can be written, the patient or their legally recognized representative must provide informed consent. This requires a discussion with a physician about the patient’s prognosis, the probability of successful resuscitation, and the potential trauma associated with CPR.
If a patient is mentally capable, they can request or consent to a DNR order directly, sometimes through a written advance directive. When a patient is unable to communicate or lacks the capacity to make medical decisions, authority transfers to a surrogate decision-maker. This surrogate is typically designated through a legal document, such as a Medical Power of Attorney or Health Care Proxy.
In the absence of a designated agent, state laws define a hierarchy of next-of-kin, often including a spouse, adult children, or parents. The surrogate’s role is to make a decision that reflects the patient’s known wishes and values. The physician must ensure the decision-maker has adequate information about the patient’s condition and the implications of the order before it is finalized.
Physician Authority to Issue the Order
The function of “issuing” and “signing” the DNR order lies exclusively with a licensed medical professional, typically the attending physician. Although the decision originates with the patient or surrogate, the DNR is a formal medical order. A physician (MD or DO) must authorize it for it to be actionable by the hospital staff, translating the patient’s consent into a legal directive within the medical record.
The attending physician, who holds ultimate responsibility for the patient’s care, is the one who signs the final form. While other members of the care team, such as nurses or residents, may facilitate the conversation, hospital policy requires the attending physician’s signature to validate the DNR. The ultimate clinical authority rests with the physician overseeing the patient’s overall treatment plan.
If a patient’s condition is deteriorating rapidly, a physician may receive a verbal order from the patient or surrogate over the phone. This order is immediately acted upon, but the physician must promptly document and co-sign the verbal order in the chart, usually within a few hours. The physician’s signature confirms the decision was made with informed consent and is clinically appropriate.
Documentation and Hospital Procedures
The moment a DNR decision is made, it must be formally documented to be operational within the hospital system. Documentation occurs through a standardized DNR form or within the patient’s electronic health record (EHR). The form requires specific details, including the patient’s name, the date and time the order was entered, and the signature of the authorizing physician.
Once signed, the order is immediately entered into the EHR, generating a flag or alert on the patient’s digital chart. This notification is crucial for communicating the patient’s status across all hospital departments, ensuring consistency of care. Nursing staff ensure the order is visible, sometimes by placing a specific color-coded DNR bracelet or tag on the patient.
The hospital DNR order is generally only valid within that specific facility for the duration of the current admission. For continuity of care outside the hospital, a separate portable order is required, such as a Physician Orders for Life-Sustaining Treatment (POLST) or Medical Orders for Life-Sustaining Treatment (MOLST) form. These portable forms are legally recognized outside the hospital, guiding emergency medical services (EMS) personnel and other healthcare providers.
Scope and Review of the DNR Order
The DNR order has a narrowly defined scope, applying only to the withholding of specific resuscitation measures. All other therapies, including intravenous fluids, medication, nutrition, and comfort measures, continue. The order does not restrict the use of antibiotics, pain medication, or procedures like blood transfusions unless specifically excluded by a more comprehensive order.
Because a patient’s medical condition can change, the DNR order requires regular review by the attending physician. This review is often mandated daily as part of physician rounds to ensure the order remains consistent with the patient’s current condition and goals of care. The patient or their surrogate retains the unconditional right to revoke the DNR order at any time by communicating the change to any member of the healthcare team.
If a patient with a DNR status requires surgery, the order must be specifically reviewed with the surgical and anesthesia teams. Anesthesia often requires temporary suspension of the DNR because intubation and ventilation may be routine parts of the procedure. Following the procedure, the order must be reinstated to reflect the patient’s original wishes.