Do-not-resuscitate (DNR) order

ALSO KNOWN AS: AND (allow natural death), DNAR (do not attempt resuscitation), no code, DNACPR (do not attempt cardiopulmonary resuscitation), end-of-life discussions, advance care planning (ACP)

DEFINITION: A do-not-resuscitate (DNR) order permits natural death for a patient who has an irreversible, terminal condition, such as advanced cancer, and receives care from healthcare professionals at home or in a medical facility. DNR documents and requirements differ by healthcare facility and by country and state. Some documents that may be required include Physician Orders for Life-Sustaining Treatment (POLST), Medical Orders for Life-Sustaining Treatment (MOLST), and Medical Orders for Scope of Treatment (MOST).

Purpose: The purpose of the order is to allow a cancer patient to experience a natural death while under the care of medical personnel. The order is only enacted when the patient stops breathing or if the heart stops beating because of the terminal illness. Even with a DNR, a natural death may not be allowed if heart or respiratory failure is caused by an unrelated event such as a car accident. Healthcare professionals providing care to patients without DNR orders, regardless of the severity of the disease, are legally required to provide cardiopulmonary resuscitation (CPR) and perform medical interventions at the time of death. These efforts must be initiated and continued until they are deemed futile by the physician or a designated professional.

The extraordinary measures performed by healthcare professionals in the event of respiratory or heart failure include CPR and placing the patient on life support. These procedures are invasive, painful, costly, and time-consuming. Appropriately performed CPR chest compressions can cause broken bones and punctured organs even in generally healthy individuals, such as accident victims. Such injuries are more likely to occur in frail individuals who are near death. The quality and duration of life following these procedures can be such that the patient and their loved ones experience significant trauma and pain for only a few extra days of life.

Another advanced form of CPR is cardioversion, or defibrillation, in which a carefully dosed electrical shock is delivered to the heart to alter its rhythm. Life support may consist of intravenous (IV) drugs that cause the heart to continue to beat. Without the medications, the heart will stop, and death will be irreversible in a few minutes, even with aggressive treatment. Mechanical ventilation is another form of life support. A tube is inserted into the sedated patient’s throat (a process called "intubation") and is attached to a mechanical ventilator (a breathing machine). If the patient needs the ventilator for an extended period, a tracheostomy (a surgical opening in the neck) will be created to attach to the machine, and prolonged sedation is not needed. However, normal speech is not possible. The ventilator causes artificial breathing. Without the machine, the patient would be unable to breathe, and life would not be sustained. Life support requires that an individual has continuous care, often in a medical facility. Some institutions cover intubation in their DNR orders, while others do not. In cases where it is not addressed, a do-not-intubate (DNI) order may be drawn up.

Procedure: In the United States, an adult who receives healthcare services and wants to be allowed to die a natural death must consult with a physician before writing a DNR order. Most individuals with DNR orders have a terminal illness, such as advanced or aggressive cancer. Electing to die a natural death allows the individual to have some control over the death process. Most individuals report they would prefer to die in their own home rather than in a hospital or nursing home. Terminally ill patients may be able to stay at home if nursing or other care is provided. If they want to die naturally at home, a DNR is needed. These patients may be transferred to the hospital if a higher level of care is needed. The DNR order must be provided to ambulance personnel transporting the patient to prevent unnecessary interventions in the event of respiratory or cardiac failure on the way to the hospital.

The first step in obtaining a DNR order is for cancer patients to discuss the issue with their medical provider. The best time to discuss these issues is before death is imminent. This allows for a less emotional and more rational discussion of the situation. Any mentally competent adult and their physician can determine if a DNR order is appropriate. If the patient is not competent to discuss the issue, family members or a designated healthcare proxy may approach the physician. If the patient (or family or proxy, if the patient is not competent) and the physician agree, the physician can write the DNR order. If the patient disagrees with the physician’s recommendations, they may select another healthcare provider, or the physician may ask for a medical ethics consultation. The consultation is provided by a medical ethics professional who is not directly involved in the patient's care. Other resources for DNR order templates and other end-of-life care directives include the Eldercare Locator website, local Area Agencies on Aging, local Veteran’s Affairs (VA) office, AARP, American Bar Association, or National Hospice and Palliative Care Organization.

Medical care: Many cancer patients and their families fear they may receive inadequate medical care if they have a DNR order. However, these orders do not interfere with routine medical care. Care of the patient changes only in its focus, not in its provision. Providers prioritize pain management, comfort, and end-of-life issues over disease management. The patient may have extensive healthcare needs, such as personal grooming, bathing, and feeding, and these activities continue. A DNR order prohibits only extraordinary measures that would prevent death or prolong life unnecessarily.

A copy must be submitted when entering home healthcare, hospice, or any other medical facility for the DNR order to be active. ICPR is medically obligated if the order is not present and respiratory or cardiac failure occurs. Some patients prominently display their DNR order by their bedside in a hospital or skilled nursing facility to minimize confusion. Out-of-hospital or nonhospital DNR orders can inform paramedics or other healthcare personnel of the patient's wishes should they experience cardiac or pulmonary arrest at home or in the community. Note that while some patients have had tattoos of the letters DNR or the phrase "do not resuscitate," healthcare providers have found such indicators to be ambiguous and may attempt resuscitation rather than risk being wrong in a life-or-death situation. Thus, those who wish to die naturally, without CPR intervention, are well-advised to create a written DNR, either alone or as part of a broader advanced directive for their end-of-life care. A patient can revoke a DNR order at any time.

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