Do Not Resuscitate Orders & How They Work
Certain people have a do-not-resuscitate medical order, commonly known as a DNR. It is important to know what a DNR is, what it means, and what to do if you ever come across someone experiencing cardiac arrest who has one.
What is a DNR Order?
A DNR documents a patient’s wishes not to receive cardiopulmonary resuscitation (CPR) if their heart stops. A DNR is written by a doctor, usually for patients with severe health conditions. If a patient has a do-not-resuscitate order, rescuers and hospital staff are told not to initiate CPR if the patient’s heart stops beating.
Which Procedures Does a DNR Include?
A DNR limits the scope of measures that may be taken to assist a patient. The laws governing DNR orders vary by state, but they typically only cover CPR. For instance, if a patient with a DNR breaks their hip, they can be given pain medications intravenously and treated just like anyone else. But if they go into cardiac arrest, their DNR will prevent resuscitation.
In some states, additional forms may specifically document a patient’s wishes related to additional medical orders for life-sustaining treatment.
What does CPR involve?
CPR delivered by medical professionals in an ambulance or in the hospital looks different from CPR delivered by a caring citizen in a public space. It’s important to know what CPR involves in each context where it is used to understand the care people with a DNR are turning down.
Chest compressions are performed to manually compress the heart to keep blood flowing throughout a person’s body when their heart stops beating. Rescuers place their hands on a patient’s chest and push down hard and fast to imitate the pumping of the heart and keep blood flowing.
Intubation is done when a hospitalized patient needs assistance breathing. Intubation is the process of inserting a tube through the mouth and into the airway. The tube is then connected to a ventilator, providing air into the lungs of the patient.
Sudden Cardiac Arrest is often caused by heart arrhythmias, which are instances where the heart does not beat normally. Some arrhythmias cannot be treated by an Automated External Defibrillator (AED) but some can and must be treated with one. AED's deliver a life-saving electric shock that restarts the heart, giving it a normal rhythm.
Patients who suffer cardiac arrest in the hospital are often administered certain medicines, like epinephrine, intravenously, meaning they are connected to an IV, which delivers the medication straight to their bloodstream.
How Do You Get a DNR?
The process of getting a DNR varies by state. Each state has specific laws, requirements, and unique forms for DNRs. The process of obtaining a DNR usually starts with a visit to your doctor, where you discuss your wishes. Sometimes patients are so sick that their health care proxy may be the one to make decisions related to a DNR on their behalf.
Sometimes, patients only start thinking about DNRs when they’re already in the hospital and being treated for a severe illness. This timing can place a significant emotional strain on a family. Putting DNR orders in place can involve some very difficult choices.
Doctors follow the laws of the states where they practice, and can advise you on a course of action. The doctor writing your DNR order is the best authority on the process in your state. Typically, you and your doctor will sign a document attesting to your wish for a DNR order. The form itself becomes a part of your records.
Some states issue wallet cards, medical bracelets, or other DNR documents so that there is a visual indicator of your wishes on your person at all times. There are simple templates available that collect and inventory your medical information so that you can carry it on your person or post in your home for rescuers to see.
Advance Care Directives
Advance care directives outline treatment decisions for patients in more detail than a DNR. Advance Directives are related to specific issues that may arise at the end of life, such as palliative, resuscitative, and supportive care.
Patients should ensure that their DNR is present in any advanced care directives and make sure that their family and health care providers are aware of their wishes regarding how they want to be treated in a medical emergency or at the end of life.
Rules for DNR Orders
Specific laws for DNR orders in the U.S. vary from state to state. Follow these general rules to ensure the validity of your DNR order:
- They cannot be verbally issued—a DNR must be documented on a standard form and signed appropriately.
- Must show the patient’s correct legal name.
- Must be dated—some states have specific rules about how long a DNR remains in effect.
- Must be signed by a physician.
How To Make a DNR Work For You
Having a DNR is useless if you do not ensure it is executed correctly. In the absence of a properly executed DNR order, rescuers will have to act. To make sure that your wishes are followed, consider a few practical steps:
- Keep a physical copy of your DNR on-hand. Some states require the original form be present, so make sure you know your state’s rules (as well as those of any you travel to).
- Make sure your friends and family are aware of your DNR order. They can locate and present a copy or the original document, as needed.
- Medical jewelry, like a bracelet or necklace, can get a rescuer’s attention.
If you’re interested in a DNR, talk to your care team to get the process started.
Take a look at some common questions we see about Do Not Resuscitate orders.
What happens if a DNR is not followed?
Failure to follow a DNR typically occurs because the emergency responders are unaware of the document or because the general rules have not been followed, resulting in an invalid DNR. However, if a DNR is valid and the care provider is aware of it, but still fails to follow it, that provider can be subject to patient complaints, disciplinary action, or legal action.