What’s DNR?

DNR means Do Not Resuscitate. A DNR is a legal note carried by a patient, barring doctors from resuscitating.  A DNR order can either be written or oral, depending on the country.

Without a DNR order, healthcare providers will immediately begin CPR procedures on a patient in case of an emergency. Cardiopulmonary Resuscitation involves mouth to mouth or machine breathing and chest compressions to restore the function of the heart in case their heart or breathing has stopped.

DNR orders are prepared before an emergency, and it gives instructions on whether to receive CPR or not during an emergency. They are written under the direction of the patient or the patient’s family, after consultation with a physician.

DNR orders are specific only to CPR and do not affect the prescription of medication or any other medical procedures. However, in some cases, a DNR order has been used to prevent other medical interventions.

Before we discuss DNR in detail, here’s a breakdown of what the article entails.

In this Write-up

  • Healthcare is a personal decision. Every individual should be allowed to make their own decisions regarding the healthcare they receive, as long as they are of sound mind.
  • DNR orders have raised a lot of debate, especially regarding the ethical considerations. These questions have resulted in many having doubts about whether to choose DNR or not, many being uneducated efficiently on the consequences of the order.
  • Doctors should, therefore, effectively and comprehensively explain the consequences of a DNR to a patient, so that they understand the full implications of their choices.
  • Reports show that currently, many patients with DNR orders have them for the sole purpose of avoiding injury from CPR.
  • With sufficient knowledge, however, a patient can understand every aspect of a Do Not Resuscitate order and maybe reconsider.
  • Next, we also need to be clarify the services DNR patients get locked out of, and those permissible, to reduce the mortality of DNR patients.
  • Currently, DNR patients are locked out on all procedures that are designed to prolong life, which puts them in a problematic scenario, lowering their chances of survival.
  • The legalities of DNR notes and warning signs must also be well established to avoid cases involving mistaken identities. For instance, tattoos (in some cases) may cause confusion regarding the validity of the DNR, which may subject the patient to unwanted resuscitation.

Why People Choose DNR and What CPR can do

According to reports from interviews of several DNR patients against full code patients in the US, the decision to choose DNR orders was a result of personal choices ranging from health and lifestyle choices, relationship factors, family and society as well as philosophical factors.

Many choose to avoid CPR because CPR is a vigorous emergency procedure that is not always successful. History shows that CPR is unsuccessful in patients with widespread infection and terminal illnesses, like cancer.

Additionally, a patient may choose to avoid Cardiopulmonary Resuscitation if they do not expect any medical benefits from the procedure. Those opting for a Do Not Resuscitate order are those awaiting imminent death and therefore opt for a more peaceful death.

Some opt for a DNR if the quality of life plummets after going through a CPR procedure. If CPR is successful, there is still a matter of side effects, like brain damage and other organ damage, which may require the patient to survive through life support.

These effects are more likely to affect the elderly and the frail, who opt for DNR to spare themselves from the trouble.

For those without a DNR order, medical care professionals will do anything in their power, as long as it is ethical to keep a patient alive.

These resuscitation procedures are designed to bring a person back from near death, but usually at the expense of wellbeing and quality of life. CPR procedures have been known to result in broken ribs, ruptured spleens, fractures, liver injuries, and airway complications.

Before resuscitation attempts, doctors are usually very optimistic and often overestimate the prognosis and lifespan of the patients. The optimism leads to increased intervention techniques administered until it is clear that nothing more can help.

Unfortunately, this clarity comes late, when the patient has hours or days to live, which leaves the patient with the stigma from all the procedures and unnecessary injuries.

Some patients also opt for a Do Not Resuscitate order for financial reasons. Terminally ill individuals and those of advanced age may choose to have a DNR to reduce medical costs that may balloon with resuscitation efforts.

Resuscitation may result in additional bills from medicines and life support systems that may strain the individual’s budget, yet they do not expect a worthwhile recovery.

Statistics show that 6 to 15 percent of patients in hospitals survive after CPR. Those in nursing homes have a 2 percent odd of survival, while those resuscitated in non-health care settings have a 4 to 38 percent chance of survival.

These statistics are worse for individuals with chronic illnesses or dementia since their survival is a minimal 1 percent. Not to forget that these survival rates have to endure the injuries that come from CPR and possible brain and heart failure.

The success of CPR increases if defibrillation happens within 5 minutes of cardiac arrest. CPR in a hospital is more successful because caregivers can detect a cardiac arrest in good time and start resuscitating the patient ASAP.

Survival after CPR in a nursing home is about three-quarters of the average rate. However, survival rates in facilities that use an Automated External Defibrillator, AED, have twice the price of survival of nursing homes and health facilities without one. Sadly, AEDs are not common in nursing homes.

CPR survival rates for patients with multiple chronic illnesses, diabetes, and heart or lung disease, is similar to survival for normal patients, while the survival rate goes down by half for patients with kidney or liver disease, or widespread cancer or infection.

Risks of DNR

Many patients who choose DNR orders mention the risks posed by CPR in their decision. CPR does cause physical injuries, like broken bones and cartilage.

Cardiopulmonary Resuscitation risks are not limited to the physical, however. Some patients who have undergone CPR have reported mental problems after the procedure.

One percent of all CPR survivors get into a coma after the process. 5 to 10 percent also need assistance with daily activities, more than they did before CPR, while a further 21 percent decline mentally, although stay independent.

However, this does not mean that patients with DNR orders do not face their challenges. For instance, patients with DNR orders get reduced care. While some patients choose DNR because they prefer less attention, some may want various levels of care.

However, doctors may misinterpret the Do Not Resuscitate preferences and opt not to provide any other appropriate care.

Patients with DNR orders are less likely to get usual medical care for issues like blood transfusion, cardiac bypass, central line placement, antibiotics, operations for surgical complications, and diagnostic tests.

Medical care providers generally assume that patients with DNR orders are not interested in any life-sustaining treatments since they do not see the benefits of these treatments.

More than 50 percent of surgeons do not give operations to patients with more than 1 percent mortality, who have signed DNR orders.

As a result of these misunderstandings, patients with DNR orders often die sooner than those without, even from cases unrelated to CPR.

A study conducted on thousands of patients, both with and without DNR orders intended to compare the survival from both groups;

For relatively healthy patients, 69% of those without DNR orders survived and left the hospital, while only a paltry 7% of those with DNR orders did. The survival rate dwindles with increasing illness, with 53% of those without DNR surviving, against 6% of those with the DNR orders.

Among patients with intensive illnesses, 6% of those without DNR survive, while there were no survivors for those with the orders.

Confusion about what services to administer to DO NOT RESUSCITATE patients, comes from the vague definition of resuscitative efforts given in the medical world. According to many doctors, resuscitative efforts may range from simple cases like treatment of an allergic reaction to surgery for kidney failure.

Doctors are, therefore, not in agreement on which treatments to deny DNR patients. A survey conducted found out that doctors preferred to intervene less frequently in scenarios involving DNR patients.

After a successful CPR, hospitals often recommend putting patients on DNR to prevent a second attempt. These orders should apply after 72 hours. However, many hospitals in the United States give these orders within 12 hours, with more than 50% of patients getting DNR orders.

When Cardiopulmonary Resuscitation happens outside a health facility, hospitals give a DNR order to 80% of the admitted patients within 24 hours of admittance. Those patients who received DNR orders got less treatment as a result, and almost all of them die in the hospital.

Researchers have also noted that discussions regarding the end of life for terminally ill patients do not happen frequently, or they do when it is too late. A study was conducted to investigate the presence and timing of DNR orders for imminently dying patients in the United States.

The reports showed that 64% of patients had a DNR at the time of their death, yet only a fifth of all the DNR orders had been written more than one week before the patient’s death. These findings show that end of life decisions happen during a patient’s final days.

The report also shows that those patients with frequent family visits and those who died in the presence of a family member were more likely to have a DNR order. These findings, therefore, encourage communication between doctors and their patients as well as including the patient’s families. 

DNR and Medical Jewelry, Advance Directive, Living Wills, POLST, Tattoos

Advance directives and living wills are documents written by patients, describing the type of care they wish to get if they are unable to speak for themselves.

A DNR order is written by a doctor or another hospital staff member concerning the patient’s living will or advance directive. Do Not Resuscitate orders can also be printed on behalf of a patient if they had an earlier directive and appointed an agent to represent the. The agent, therefore gets consulted for the DNR order.

It is important to note that, in the United States, an advance directive or a living will not ensure that a patient gets treated under the DNR protocol since neither the advance directive nor living can legally bind a doctor.

They are only legally binding in the appointment of a medical representative, but not in treatment decisions.

Physician Orders for Life-Sustaining Treatment (POLST) are documents given when a DNR gets provided outside a hospital.

DNR orders can also be in the form of medical bracelets, wallet cards, or medallions from approved providers. This jewelry helps identify DNR patients in non-hospital settings and at home.

In the United States, there are policies, procedures, and paperwork that accompanies such forms of DNR, and personnel is required to act according to varying state rules on the same.

Currently, there is a growing trend of using DNR tattoos, which are replacing other forms of DNR. These tattoos get often placed on the chest. However, legally, tattoos are not considered as valid forms of DNR.

Do Not Resuscitate orders in the form of tattoos raise several ethical dilemmas, since the patient may change their mind over resuscitation. Yet, the symbol is difficult to remove, so it raises plenty of confusion among healthcare providers.

Additionally, many people get tattoos while under the influence of alcohol and other drugs. These DNR tattoos can, therefore, be acquired when the patient is not exhibiting sound judgment, which will affect any resuscitation attempts. Luckily, tattoos are not accepted forms of DNR.

DNR Ethical Issues

DNR orders have brought up several ethical debates in recent times. For instance, when a patient with a DN is undergoing surgery, many medical institutions revoke their DNR automatically. The argument states that CPR in the operating room is more successful than Cardiopulmonary Resuscitation in general conditions.

The ethical argument comes in, that the health facilities do not allow the patient to reconsider their DNR orders, but go ahead and rescind them on their own.

In case of conflict over DNR status, the hospital ethics committee is supposed to mediate between doctor, patients and their families.

However, many members in the ethics committee do not have sufficient ethics training, may not have an adequate medical practice, and have a conflict of interest. They are, therefore, more likely to side with the doctors, often trumping the patient’s wishes.

Another point of concern is: there has been a noted racial bias in the adoption of DNR. Non-Latino white patients are the most likely to have a DNR order, at 45%, with black patients occupying 25% and Latino patients at 20%.

There is also an issue where a patient may wish against resuscitation but does not possess the appropriate documentation, or they may be disabled, so their next of kin makes the decisions for them. The decision may be contrary to the patient’s wishes.

Another ethical dilemma comes up when a patient with a DNR attempts suicide, and the only way they can get treatment requires the use of ventilation tubes or CPR. In such scenarios, the principle of beneficence is considered over patient autonomy, where the physician usually revokes the DNR.

Another dilemma occurs when a medical error is made involving a patient with a DNR, where the only way to correct the mistake is the use of CPR or ventilation. Doctors do not know whether to revoke the DNR or not.

Another ethical issue arises in cases where a patient may not have comprehensively understood the requirements of the DNR order. For instance, there have been cases where patients with Do Not Intubate orders, DNI, have requested for intubation.

Such scenarios raise questions about whether DNR patients may want CPR in some situations also. It also raises alarms about the information given by doctors to patients regarding DNR orders, with many under the belief that physicians may leave crucial information while discussing a DNR with patients.

It is also disturbing that a majority of doctors opt for a DNR order for themselves, with up to 90% of doctors choosing to have DNR orders in case of a terminal illness. Doctors usually tend to forego resuscitation themselves. Yet they are more than willing to give high-intensity care to patients without a DNR order.

Another ethical dilemma comes from the use of Implantable Cardioverter Defibrillator (ICD), where doctors deactivate the ICD in cases of medical futility involving DNR patients.

Doctors argue that deactivating the ICD is not ethically different from withholding CPR and is, therefore, within the directives of the DNR. Some, however, argue that deactivating a pacemaker is different, and it cannot be ethically endorsed.

United States and DNR Laws

In the United States, Do Not Resuscitate orders are acceptable in different forms, depending on the state. For instance, some advance directives and living wills may not be accepted by EMS as valid.

The EMS insists on having a DNR form signed by a physician in conjunction with the living will or advance directive, regardless of the instructions given in those documents. In the absence of the signed form, the EMS may attempt resuscitation.

DNR in the United States was first legally approved after Congress passed into law, the Patient Self-Determination Act in 1991. The activities require a hospital to respect the patient’s decisions regarding their healthcare.

Medical decisions can be made for an incapacitated patient by their next of kin in forty-nine states. In Missouri, however, there is a Living Will Statute that requires any signed advance directive for a DNR or DNI in a hospital, to be accompanied by two witnesses.

CPR cannot get administered if there is a valid DNR order present. Many states, however, do not accept living wills in a pre-hospital setting, and caregivers in those facilities are required to commence on resuscitation efforts unless a state-specific document is filled and signed by a physician.

Guidelines in the United State also allow for organ donation after CPR, but not after the death of a patient with a DNR. Kidneys and liver from a patient who underwent unsuccessful CPR, with the efforts proceeding until an operating room are eligible for donation.

Patients who do not get the return of spontaneous circulation after CPR may be considered for organ donation, where such programs exist. European guidelines encourage organ donation. All patients resuscitated from CPR, but who proceed to die must be scanned before organ donation.

An average of three organs can be taken from patients who are eligible for donation. However, patients with a DNR are not allowed to donate their organs.

Wrapping Up

There have been proposals for patients to choose Allow Natural Death (AND) forms in place of Do Not Resuscitate orders.

While DNR orders discourage restarting breathing or restarting a stopped heart, AND rules ensure that only comfort measures get taken. AND orders are more directed towards what should not happen, which dictates that all actions that prolong a natural death should get avoided.

AND orders, however, are only available for terminally ill patients.

All in all, the subject of DNR orders, on whether they are beneficial or not, is one that will rage on for quite some time. In the meantime, patients should make choices regarding their end of life decisions early and make them known to the relevant parties.