Decisions On Your DNR

A DNR (Do Not Resuscitate) order is a physician’s order stating that hospital staff should not institute CPR if you experience a cardiac or respiratory arrest. It is generally reserved for terminally ill patients or those who are very elderly and medically frail, who would likely not survive a cardiac arrest. The order is written in alignment with your wishes when admitted to the hospital and applies to that single hospital stay. When you are discharged, the DNR order becomes null and void. 

An out-of-hospital DNR order, on the other hand, is a durable order that is valid both in and out of the hospital unless or until it is revoked. It is written by a doctor when you both agree to allow a natural death in the event that you stop breathing or have a cardiac arrest. In states where such orders are recognized, first responders and emergency personnel cannot legally perform CPR if the order is presented to them.  

With that being said, there is currently no national DNR law, and state requirements may differ significantly. According to the American Society for Healthcare Risk Management, if you wish to avoid CPR you should have both an advance healthcare directive (living will) and a durable power of attorney in place, as well as a DNR and/or a POLST. This may help ensure that your wishes are honored if you find yourself in the emergency room. 

If you live in a state where out-of-hospital DNR orders are recognized, your doctor will write the order on a state-specified form. Most EMS personnel recommend that the order be taped in a highly visible location, such as a refrigerator or your bedroom door. The DNR should also be in your electronic health record, although hospital personnel may not take the time to look for it if you are taken to the emergency room in cardiac arrest. To avoid that scenario, wear a Medic-alert bracelet that states that a DNR order is on file. 

Keep in mind, too, that neither a DNR bracelet or a DNR tattoo will be honored if a written physician’s order does not exist. 

Sources

“Do Not Resuscitate (DNR) Laws by State 2025”. World Population Review. https://worldpopulationreview.com/state-rankings/do-not-resuscitate-laws-by-states

Because illness and accidents can strike at any age, every adult should have an advance directive and a durable power of attorney for health care. According to the Cleveland Clinic, this means anyone over the age of 18. In most states, emancipated minors may also execute an advance directive if they choose to do so. 

That being said, a significant number of American adults do not have an advance directive in place. Although the number has been creeping steadily upward in recent years, a 2023 national survey conducted by Compassion and Choices found that 93% of adults recognize that it is important to have an advance directive, but only 37% of those asked had completed one. Of those that had, only 12% had shared their advance directive with their doctor, and nearly 60% had not selected a surrogate decision maker. 

Further, 85% of survey participants said they felt comfortable discussing end-of-life matters with their primary care provider but only 17% had.

In order to address this issue legally, some states have enacted “surrogate consent statutes,” which designate the individual or individuals who have the legal right to make medical decisions for a person who has no advance directive and cannot speak for themselves. 

Generally, surrogate consent laws fall into two categories: hierarchy surrogate consent laws and consensus surrogate consent laws. Most states that have enacted such laws have chosen to impose a hierarchical consent scheme with family members named in a descending order, which is generally the following:

• A spouse
• An adult child 
• A parent
• An adult sibling

Some states also include nieces and nephews, grandchildren, aunts and uncles and — in some cases — any living relative. In other states, a “close friend” may be authorized to make decisions, though their input may carry less weight than next-of-kin. 

It is important to be aware, however, that these laws are not consistent across the U.S., and many statutes impose limitations on the decisions that these default surrogates can make. Further, state laws can change frequently, and it is difficult for the average person to keep track of changes in real time. Therefore, it is vital that every person over the age of 18 have a written advance directive that designates a healthcare surrogate whom they trust to make medical decisions on their behalf. 

Sources

“Advance Care Planning and Advance Directives”. Cleveland Clinic. https://my.clevelandclinic.org/patients/information/medical-decisions-guide/advance-directives 

“Recent Updates to Default Surrogate Statutes”. American Bar Association. https://www.americanbar.org/groups/law_aging/publications/bifocal/vol44/bifocal-vol-44-issue3/recent-updates-to-default-surrogate-statutes/ 

The decision to forgo life-sustaining treatment is rarely an easy one. No one wants to die, but for many people, the time comes when treatments are no longer effective, sustaining life through artificial means no longer makes sense or quality of life is poor. When this happens, it’s important to have a conversation with your doctor and your loved ones about your disease progression, your priorities and the goals of your medical care. It’s also important to acknowledge the reality that in many situations, CPR will not save your life but will simply prolong your death. 

According to Brigham and Women’s Faulkner Hospital, some situations where a DNR order would be appropriate include: 

• When CPR would provide no medical benefit. For example, CPR is unlikely to restore heart function or breathing in patients with widespread infections, advanced cancer, severe heart disease or other terminal illnesses.
• When CPR would damage the person’s quality of life. Especially in people who are very old and frail, CPR may be only partially successful. The person’s heartbeat may be restored, but they may have broken ribs, brain damage or be dependent on breathing support for the rest of their lives. 
• Death is expected soon. People who have a terminal illness and/or are approaching the end of life may wish to avoid aggressive medical care in favor of a natural death. 

In most cases, you, your family, and healthcare providers will agree when and if a DNR is appropriate. However, in rare cases, a doctor may disagree with your decision to forgo CPR. If this occurs, and there is no way to resolve the conflict through additional discussion, you may request that the doctor transfer your care to another provider. If the doctor refuses to do so, you or your family can then consult with a patient advocate, the hospital ombudsman or administrator and request that they resolve the dispute.   

Sources

“MOLST: Massachusetts Medical Orders for Life-Sustaining Treatment”. Brigham and Women’s Faulkner Hospital. https://www.brighamandwomensfaulkner.org/patients-and-families/advance-care-directives/molst

CPR is an acronym for cardiopulmonary resuscitation. According to MedlinePlus, it may include:

• Rescue breathing (to deliver oxygen to your lungs)*
• Chest compressions to pump blood from your heart to the rest of your body
• A breathing tube to keep the airway open
• Medications delivered intravenously, into a bone or directly into the heart
• Electric shocks to restore heart rhythm

*Note: In 2010, CPR guidelines for untrained laypersons were updated to indicate that compressions alone (without rescue breathing) could circulate the remaining oxygen in the bloodstream of a victim of sudden cardiac arrest. However, trained laypeople and healthcare providers will always initiate both rescue breathing and chest compressions for a person with no pulse.

CPR is a highly invasive procedure, and offers differing levels of success. Despite public perception, patients who suffer sudden cardiac arrest in the community (for example, at home or at work) have an overall survival rate of just over 10%, and only 8.3% survive with neurological function intact. Patients who experience cardiac arrest in a hospital setting fare somewhat better, with an overall survival rate of just under 25%. 

But overall survival rates can be very deceiving. For example, a 2014 study reported in Age and Ageing found that nearly 40% of elderly patients who received CPR in a hospital setting initially survived. (In other words, their hearts started beating again.) But more than half of those patients later died in the hospital without ever returning home. What’s more, a person’s chance of leaving the hospital after “successful” CPR decreased with age. Between the ages of 70 and 79, a person’s chance of being discharged was nearly 19%. This fell to 11% in patients who were 90 years old or older. 

Furthermore, even properly performed CPR can cause serious harm, the American Heart Association notes. Chest compressions may cause rib fractures and fractures of the sternum (the flat bone in the center of the chest). It may also lead to pneumothorax (free air in the chest cavity), hemothorax (bleeding in the chest cavity), bruising of lung tissue and lacerations of the liver and spleen. Fat emboli (particles of fat in the bloodstream that may lodge in the lungs, brain or heart) can also occur. What’s more, emergency protocols dictate that once CPR is started, providers must continue until a heartbeat is re-established or the person is obviously dead. Depending on the circumstances and setting, this can lead to prolonged efforts that some physicians liken to physical abuse.

Sources

“Do-not-resuscitate order”. MedlinePlus. https://medlineplus.gov/ency/patientinstructions/000473.htm 

“What Is Cardiac Arrest?”. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/cardiac-arrest 

“AHA Releases 2015 Heart and Stroke Statistics”. Sudden Cardiac Arrest Foundation. https://www.sca-aware.org/sca-news/aha-releases-2015-heart-and-stroke-statistics 

“The chance of survival and the functional outcome after in-hospital cardiopulmonary resuscitation in older people: a systematic review”. Age and Ageing. https://academic.oup.com/ageing/article-abstract/43/4/456/2812217?redirectedFrom=fulltext

“Part 3: Adult Basic Life Support”. AHA Journals. https://www.ahajournals.org/doi/full/10.1161/circ.102.suppl_1.i-22 

“The Hidden Harms of CPR”. The New Yorker. https://www.newyorker.com/news/the-weekend-essay/the-hidden-harms-of-cpr

A do not resuscitate order is a doctor’s order that instructs healthcare personnel not to institute CPR if a patient’s heart or breathing stops. As a rule, it is considered appropriate only for patients who would not benefit or may actually be harmed by resuscitation, such as those who are terminally ill or very elderly and medically frail. 

Until recently, only one type of DNR order existed. However, some U.S. states have now instituted two levels of DNR: DNR Comfort Care and DNR Comfort Care-Arrest. Both have the goal of allowing a patient to refuse extraordinary life-saving measures but differ in important ways. 

• DNR Comfort Care is what may be viewed as a traditional DNR. It is appropriate for patients for whom CPR would likely not extend life and could result in significant harm. When a DNR Comfort Care order is in place, healthcare personnel, including EMS first responders, are required to provide any measures that could enhance the patient’s comfort, such as pain medicine or oxygen, but not to perform CPR or employ other extraordinary means to keep the person alive. 

• DNR Comfort Care-Arrest is an order that allows healthcare providers to institute life-saving measures until the point that a person’s heart or breathing stops. For example, a person experiencing a life-threatening infection might receive antibiotics, oxygen, and powerful medications to support their blood pressure. But if that person stopped breathing, they would not receive CPR. 

Additionally, some hospitals (for example, Ohio’s Cleveland Clinic) allow a physician to specify what resuscitative measures a patient should receive in the event of a cardiac arrest. For example, the DNR order might specify that providers can insert a breathing tube and institute CPR, but they are not to give electric shocks to restart the heart. If a patient wishes to be provided life-saving treatment but not have a breathing tube, this order is sometimes referred to as Do Not Intubate or DNI. 

Sources 

“Do-Not-Resuscitate (DNR)”. Cleveland Clinic. https://my.clevelandclinic.org/health/articles/8866-do-not-resuscitate-orders