What is a DNR Order?

If you land in the hospital and your body is shutting down, you have the option to instruct medical staff not to resuscitate you. This is where a DNR order comes in. Let’s talk about what a DNR order is, how it works, and more.

What is a DNR Order?

A “Do Not Resuscitate” Order is a medical order from a doctor. It instructs the medical staff to not perform “heroics” if a patient’s heart or lungs stop. A DNR order enables the patient, or the patient’s family, to choose whether they want resuscitation methods executed during such an emergency, or not. It’s specifically for resuscitation. It does not include other medical instructions such as pain management, medication, and nutrition. 

A DNR order is a status that a patient is given in the hospital. It’s noted in a patient’s hospital chart, medical files, and other records. They’ve opted not to be resuscitated in case their heart stops beating or their lungs stop breathing. 

“Do Not Resuscitate” is the opposite of “Full Code.” This means that medical staff will execute all appropriate heroics. “Heroics” pertains to the medical actions executed to attempt to prolong a patient’s life even with minimal chances of success.

3 Categories of End-of-Life

There are three common facets of end-of-life care in a medical situation, namely:

(1) Selective heroics. Going into a hospital with a grim prognosis with no hope of recovery, a patient opts for a specific level of heroics. 

(2) Comfort care. Going into a hospital with a grim prognosis with no hope of recovery, a patient foregoes treatment and opts for comfort care. This type of care entails soothing a patient and alleviating their quality of life while respecting their wishes. It can involve managing physical comfort, meeting mental and emotional needs, and accommodating spiritual needs. 

(3) DNR and withdrawal of care. A patient is on life support with no hope of recovery, so the patient or the patient’s family withdraws care. 

4 Types of Resuscitation Methods

CPR, short for “cardiopulmonary resuscitation,” is the treatment doctors perform when a patient’s heart or lungs stop. There are four main methods of CPR:

(1) Chest compressions to keep the blood flowing until the heartbeat resumes. 

(2) ACLS Protocol, which entails injecting medication in the veins to deal with different types of heart rhythm. 

(3) Electric shock, which involves the usage of charged paddles to shock the heart if it stops or has an irregular rhythm. 

(4) Intubation, which involves inserting a big straw into the patient’s mouth and windpipe to mechanically breathe for them. 

If you, or a loved one, are nearing the end of life or suffering an illness with a grim prognosis, you should consider these methods so that you can make an informed decision for yourself. Fully understand the medical condition and know what to expect. Have an honest conversation with your doctor about the advantages and disadvantages of resuscitation. If necessary, seek multiple opinions from qualified medical professionals who are knowledgeable about the condition.

Why You Should Understand What a DNR Means

Even if you might not currently have a family member suffering from a severe or fatal medical condition, understanding end-of-life care options is essential as it’s something most people will eventually go through. DNR is typically for cases of emergency, but it can also be a facet of a hospice care plan. 

Guiding patients and families to make an informed decision:

In many cases, family members may still be hesitant to greenlight a DNR order as they feel guilty about contributing to the outcome. But there is a point where extending life through resuscitation only extends suffering. It’s a balancing act that requires confidence in your medical team, and communication with your doctors to fully understand the prognosis and the value of resuscitation and further care. 

No doctor or medical professional wants to recommend DNR. But in this difficult situation, it’s critical to compartmentalize the situation. Family members must use “substituted judgment.” They must not say what they want for their loved ones. Rather, they should consider what the patient would choose if they could see the situation and speak for themselves. 

Ensuring that the patient and medical staff agree on the level of care:

There is increasing medical literature that shows that people are often confused about getting heroics done (or not done) when their heart or lungs stop versus receiving good and appropriate care.

But it’s critical to understand that decisions on resuscitation are separate from decisions on treatment and care. A patient may choose to have certain, or no, heroics done. But they still want to receive aggressive care or comfort care. In this case, ensure that this is explicitly communicated to the doctor and medical staff.

A doctor can recommend a DNR based on the prognosis. However, there are no set criteria for this. Different doctors and hospitals will apply DNR status at different rates for the same illness or prognosis. For example, a study involving 8,233 patients with intracerebral hemorrhage treated in 234 hospitals found that the percentage of DNR orders “varied from 0% to 70% across hospitals.” It’s a judgment call every time.

But in some cases, choosing DNR becomes a self-fulfilling prophecy. According to a study in the Archives of Surgery, 1 in 4 people with DNR orders died within a month of surgery, which is twice the rate of those without DNR orders. 

Some studies argue that patients with DNR status have worse diseases or are truly likely to not make it. But other articles suggest that it may be because patients with DNR status are offered less care. A study conducted on patients in California hospitals found that early DNR assignment is linked to a decrease in “potentially critical hospital interventions, procedures, and survival to discharge, and wide variability in practice patterns between hospitals.” 

This decline in treatment may be due to miscommunication or varied understanding between health care providers on what a DNR order means. Some studies have shown that a DNR order can subconsciously impact how doctors and nurses treat patients such that they come by the room less often or order fewer tests. Furthermore, some may assume that because patients have refused resuscitation means they would prefer not to receive other interventions.

Essential Questions to Ask About DNR

Below are additional commonly asked questions about DNR to guide your decision-making.

  • Can a family revoke a DNR order?

It’s critical to remember that if the patient can make an informed decision about DNR ahead of time, they always have the right to rescind that decision and request resuscitation. So, if you decide to change your mind, talk to your doctor or medical team immediately. Cascade this decision to all family members and caregivers. Destroy all existing documents that indicate your previous decision to avoid confusion. 

If the patient had previously decided on a DNR and then becomes unable to state their final wishes due to illness or injury, but the doctor has already written a DNR order in line with the patient’s request, the family cannot override this decision. 

If the patient has assigned someone to speak on their behalf, such as a family member, legal guardian, or health care agent, they can agree to a DNR for the patient. 

Is the patient be unable to speak for themselves and did not previously assign anyone to represent them? A family member can agree to a DNR order on their behalf. But this is only in cases when the patient is unable to make medical decisions on their own.  

  • How do you make a DNR order?

If a patient, or a patient’s representative, has opted for DNR, inform the doctor and medical staff of this decision. If the doctor does not agree with this decision, they may transfer the patient to a different doctor who will carry out this request.

Otherwise, the doctor will proceed with filling out a DNR order form. If the patient is in the hospital, the DNR order will be in their medical chart. If the patient has a non-hospital arrangement, the doctor can advise on how to get a bracelet, wallet card, and other DNR documentation to keep at home. For patients with long-running medical conditions, have a living will that you will cascade to family members and health care agents.

Importantly, remember that DNRs can work differently depending on where you live. When in doubt, talk to a medical professional or lawyer to understand how it works in your state. 

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Author: Jonathan Baktari MD

CEO of e7health and US Drug Test Centers

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Jonathan Baktari MD

Jonathan Baktari, MD brings over 20 years of clinical, administrative and entrepreneurial experience to lead the current e7 Health team. He has been a triple board-certified physician with specialties in internal medicine, pulmonary and critical care medicine. He has been the Medical Director of The Valley Health Systems, Anthem Blue Cross Blue Shield, Culinary Health Fund and currently is the CEO of two healthcare companies.
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