The Complete Guide to Do-Not-Resuscitate Orders (DNRs)

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Categories: Knowledge Base, Life Saving Advice

There is a lot of confusion surrounding do-not-resuscitate (DNR) orders. For instance, a DNR doesn’t cover most lifesaving interventions, and the reasons for establishing a DNR are much more nuanced than many people realize. We’re here to lift the veil on this commonly misunderstood topic.

What Is a Do-Not-Resuscitate Order

A do-not-resuscitate order, or DNR, is a formal medical order that a patient can establish with their doctor. A DNR dictates that the patient does not wish to receive CPR or have their heart restarted in the event that their heart stops. The order does not affect other life-prolonging measures like the use of feeding tubes; it only applies to resuscitation.

A DNR order must be written by a doctor. The doctor will typically explain your options to you and your family, outlining what the DNR entails. With your consent, the doctor will create the order and enter it into your medical record. It will then be visible and applicable to any medical professionals who treat you.

While the purpose of a DNR is to advise medical personnel, it may be used outside of a clinical setting as well. For instance, a person may have a “Do Not Resuscitate” tattoo or bracelet to prevent bystanders from aiding them outside of the hospital, and nursing homes will sometimes maintain DNR records for the people in their care.

Why Do People Choose to Have a DNR?

As many as four out of five people receiving end-of-life care are opposed to the use of aggressive lifesaving measures. While CPR and defibrillation can be highly effective for relatively healthy people, they don’t significantly prolong the lives of people who are already terminally ill or receiving end-of-life care. For these individuals, lifesaving measures can actually be a painful hindrance. When these measures do work in the short term, they can further compromise the patient’s quality of life. For example, some frail patients may suffer brain or organ damage when aggressive lifesaving measures are taken.

A patient may opt for a DNR if:

  • Resuscitation is unlikely to be successful
  • Resuscitation is unlikely to prolong the patient’s life for very long
  • Resuscitation could endanger the patient’s quality of life
  • The patient has a terminal illness and does not expect to live for much longer

To put it in its simplest terms, a DNR order allows a patient to say “I just want to let nature take its course.”

Can a Healthy Person Get a DNR?

While do-not-resuscitate orders are commonly sought by aging and terminally ill patients, it is possible for a healthy person to get a DNR. In fact, many doctors have their own DNRs in place.

But while most states will allow any adult to establish a DNR, it’s not always a good idea. If you don’t meet any of the criteria listed above, you may be putting yourself at risk of facing a preventable death when effective interventions are available.

Some people will request a DNR order because they believe that resuscitation isn’t effective or that it does more harm than good. While it’s true that over 90% of out-of-hospital cardiac arrests are fatal, this is largely due to a lack of intervention and not because of intervention itself.

When CPR is used in conjunction with an automated external defibrillator, a patient’s chances of survival can increase by up to five times. The key is rapid intervention, and for otherwise healthy individuals, it can mean many more fruitful and productive years. That’s why we recommend AED devices in all public places.

Other Types of End-of-Life Orders

A DNR may sound like an all-encompassing rejection of lifesaving interventions, but it’s actually very limited in scope. Non-cardiac emergencies are covered by other types of orders including living wills, DNIs, and ANDs.

DNR vs Living Will

A DNR order is sometimes confused with a living will, but these are two distinct orders with different areas of focus.

A living will covers ventilators, feeding tubes, blood transfusions, dialysis, and other interventions that may be attempted during a health emergency. Living wills are created by both healthy and ailing individuals, and they’re designed to take effect if you cannot express your wishes in the midst of a health emergency. They do not cover resuscitation.

A do-not-resuscitate order is strictly focused on resuscitation in the form of CPR, cardiac drugs, or defibrillation. It says that medical personnel will not try to revive you if your heart stops. Unlike living wills, these orders are seldom requested by healthy individuals; they’re most commonly requested by frail, ailing, and elderly patients on whom CPR might be more harmful than beneficial.

DNR vs DNI

DNI stands for “do not intubate.” Whereas a DNR prohibits doctors from resuscitating a stopped heart, a DNI prohibits doctors from inserting a breathing tube to prolong a patient’s life. A DNI does not apply to resuscitation.

For an ailing patient who wants to bar all aggressive life-saving measures, it may be advisable to establish both a DNR and a DNI. A DNR covers cardiac arrest while a DNI covers respiratory failure and related conditions.

DNR vs AND

An allow-natural-death order (AND) is used by certain hospitals in place of a traditional DNR. Whereas the classic DNR disallows all attempts to revive a patient with no heartbeat, an AND more specifically dictates that medical personnel should only use comfort measures to control pain and other symptoms.

For instance, an AND may permit doctors to withhold resuscitations, intubations, and any other treatments that only serve to prolong the person’s life without preserving the quality of life. In many cases, it can serve the purposes of a DNR, a DNI, and a living will, as it’s strictly concerned with ensuring the patient’s comfort while allowing nature to take its course.

Can a Family Member Override a DNR?

Doctors are bound to honor a patient’s wishes in the event of a DNR, and no family member has the authority to override those wishes if the order is in effect at the time of the emergency. It’s not uncommon for a patient’s family to demand resuscitation when the unconscious patient can’t speak for themselves, but such demands are seldom heeded if a DNR is in place—though in the case of an EMS (Emergency Response Services) response outside of the patient’s treating hospital, the DNR paperwork must be presented in order for the responding professional responders to honor it.

The whole purpose of a DNR is to allow the patient to make this important decision while they’re conscious, calm, and of sound mind, and that decision cannot be reversed without the patient’s consent.

The only exception to the rule is if the DNR order was requested by someone authorized to make medical decisions on behalf of the patient, such as a healthcare agent or guardian. If the individual established the DNR order on the patient’s behalf, they would generally have the authority to request that the order be reversed. But the individual must be an officially recognized caretaker in charge of a patient unable to care for themselves. It’s not enough to simply be a spouse or relative.

How to Get a DNR

For anyone interested in establishing a DNR, the process is as simple as making an appointment with your doctor or a general practitioner. Explain your wishes to them, and they’ll outline your options and fill out the order on your behalf. If they’re unable to carry out your wishes, they’ll refer you to a doctor who can.

Getting the order is easy. But when you make the decision to establish a DNR, there are other steps you’ll need to take as well:

  • Notify your family of your decision. Ensure they are prepared to present the paperwork to responding EMS if outside of a hospital. You’ll also need to notify your healthcare agent and any caretakers.
  • Speak to your doctor about obtaining a wallet card, bracelet, or other identifying documentation to alert the public of your wishes.
  • Establish a living will that includes your DNR wishes. While a living will is separate from a do-not-resuscitate order, it’s often created around the same time because it addresses similar end-of-life decisions.

If you already have a DNR in place and you’ve decided that you want to reverse it, speak to your doctor immediately.

What Happens if You Resuscitate Someone with a DNR?

Do-not-resuscitate orders are intended primarily for medical personnel, but what happens when a cardiac emergency occurs outside the hospital? Can a bystander perform CPR or defibrillate a patient with a DNR bracelet?

Respecting the wishes of the patient is always recommended. However, if you encounter someone with a DNR and you nevertheless take steps to save their life, you should be protected by your state’s Good Samaritan Law. Every state has some form of Good Samaritan Law, which is designed to protect untrained laypersons who provide lifesaving assistance in good faith, regardless of the outcome.

For example, California Health and Safety Code §1799.102 notes that “No person who in good faith, and not for compensation, renders emergency medical or nonmedical care at the scene of an emergency shall be liable for any civil damages resulting from any actor omission commonly known as ‘The Good Samaritan Law.’”

Generally, there is only one instance in which a Good Samaritan Law won’t protect you: in instances of negligence. In other words, you’re expected to respond with as much competence and care as any reasonable person would in the situation.

To learn more about Good Samaritan Law as it pertains to DNRs, please refer to our comprehensive guide, Can You Perform CPR on a Victim With a DNR Order?

DNR Basics – A Recap

Once you understand the basics, do-not-resuscitate orders are quite simple:

  • A DNR tells medical personnel that you don’t wish to be resuscitated if your heart stops; it doesn’t cover any other conditions or interventions.
  • Anybody can have a DNR order created, but they’re best reserved for frail, elderly, or terminally ill patients who would likely receive little to no benefit from resuscitation.
  • Only the patient or their authorized medical caretaker can make decisions regarding a DNR.
  • If you attempt to resuscitate a DNR patient as a bystander, you’ll almost always be protected by your state’s Good Samaritan Law.

For more information about do-not-resuscitate orders, speak to your doctor right away.