Do not resuscitate
||This article contains weasel words: vague phrasing that often accompanies biased or unverifiable information. (August 2013)|
In medicine, a "do not resuscitate" or "DNR", sometimes called a "No Code", is a legal order written either in the hospital or on a legal form to respect the wishes of a patient not to undergo CPR or advanced cardiac life support (ACLS) if their heart were to stop or they were to stop breathing. The term "code" is commonly used by medical professionals as jargon for "calling in a Code Blue" to alert a hospital's resuscitation team. The DNR request is usually made by the patient or health care power of attorney and allows the medical teams taking care of them to respect their wishes. In the health care community "allow natural death" or "AND" is a term that is quickly gaining favor as it focuses on what is being done, not what is being avoided. Some criticize the term "do not resuscitate" because it sounds as if something important is being withheld, while research shows that only about 5% of patients who require CPR outside the hospital and only 15% of patients who require CPR while in the hospital survive. Patients who are elderly, are living in nursing homes, have multiple medical problems, or who have advanced cancer are much less likely to survive.
A DNR does not affect any treatment other than that which would require intubation or CPR. Patients who are DNR can continue to get chemotherapy, antibiotics, dialysis, or any other appropriate treatments.
Alternative namings and abbreviations for this order are used depending on the geographic region. DNR (Do Not Resuscitate) is a common abbreviation in the United States, Canada and the United Kingdom. It may be clarified in some regions with the addition of DNI (Do Not Intubate), although in some hospitals DNR alone will imply no intubation. Clinically, the vast majority of people requiring resuscitation will require intubation, making a DNI alone problematic.
Some areas of the United States and the United Kingdom include the letter A, as in DNAR, to clarify "Do Not Attempt Resuscitation." This alteration is so that it is not presumed by the patient/family that an attempt at resuscitation will be successful. Since the term DNR implies the omission of action, and therefore "giving up", some have advocated for these orders to be retermed Allow Natural Death. New Zealand and Australia (and some hospitals in the UK) use the term NFR or Not For Resuscitation. Typically, these abbreviations are written without periods between the letters, i.e. AND/DNR not A.N.D./D.N.R..
Another synonymous term is "not to be resuscitated" (NTBR).
Until recently in the UK it was common to write "Not for 222" or conversationally, "Not for twos." This was implicitly a hospital DNR order, where 222 (or similar) is the hospital telephone number for the emergency resuscitation or crash team.
DNR compared with advance directive and living will
In contrast, it is a physician or hospital staff member who writes a DNR "physician's order," based upon the wishes previously expressed by the individual in his or her advance directive or living will. Similarly, at a time when the individual is unable to express his wishes, but has previously used an advance directive to appoint an agent, then a physician can write such a DNR "physician's order" at the request of that individual's agent.
These various situations are clearly enumerated in the "sample" DNR order presented on this page.
It should be stressed that, in the United States, an advance directive or living will is not sufficient to ensure a patient is treated under the DNR protocol, even if it is his wish, as neither an advance directive nor a living will is a legally binding document. It is also the case that the wishes expressed in an advance directive or living will are not binding. But also see the legal discussion presented in the next section.
Usage by country
DNR documents are widespread in some countries and unavailable in others. In countries where a DNR is unavailable the decision to end resuscitation is made solely by physicians.
DNRs are not recognized by Jordan. Physicians attempt to resuscitate all patients regardless of individual or familial wishes. In Israel, it is possible to sign a DNR form as long as the patient is dying and aware of their actions.
England and Wales
In England and Wales, for resuscitation, as for any medical treatment, by default only the patient can give informed consent, if they have capacity as defined under the Mental Capacity Act 2005. If they lack capacity relatives will often be asked for their opinion out of respect but it does not have hard legal force on the doctor's decision. In this situation, it is their doctor's duty to act in their 'best interest', whether that means continuing or discontinuing treatment, using their clinical judgment. It is important to note, that patients and relatives cannot demand treatment (including CPR), which the doctor believes is futile. Alternatively, patients may specify their wishes and/or devolve their decision-making to a proxy using an advance directive, which are commonly referred to as 'Living Wills'.
In Scotland, the terminology used is "Do Not Attempt Cardiopulmonary Resuscitation" or "DNACPR". There is a single policy used across all of NHS Scotland. The legal standing is similar to that in England and Wales, in that CPR is viewed as a treatment and, although there is a general presumption that CPR will be performed in the case of cardiac arrest, this is not the case if it is viewed by the treating clinician to be futile. Patients and families cannot demand CPR to be performed if it is felt to be futile (as with any medical treatment) and a DNACPR can be issued despite disagreement, although it is good practice to involve all parties in the discussion.
In the United States the documentation is especially complicated in that each state accepts different forms, and advance directives and living wills are not accepted by EMS as legally valid forms. If a patient has a living will that states the patient wishes to be DNR but does not have an appropriately filled out state sponsored form that is co-signed by a physician, EMS will attempt resuscitation.
The DNR decision by patients was first litigated in 1976 in In re Quinlan. The New Jersey Supreme Court upheld the right of Karen Ann Quinlan's parents to order her removal from artificial ventilation. In 1991 Congress passed into law the Patient Self-Determination Act that mandated hospitals honor an individual's decision in their healthcare. Forty-nine states currently permit the next of kin to make medical decisions of incapacitated relatives, the exception being Missouri. Missouri has a Living Will Statute that requires two witnesses to any signed advanced directive that results in a DNR/DNI code status in the hospital.
In the U.S., cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) will not be performed if a valid written "DNR" order is present. Many US states do not recognize living wills or health care proxies in the prehospital setting and prehospital personnel in those areas may be required to initiate resuscitation measures unless a specific state sponsored form is appropriately filled out and cosigned by a physician.
Do not resuscitate orders are similar to those used in the United States. In 1995, the Canadian Medical Association, Canadian Hospital Association, Canadian Nursing Association, and Catholic Health Association of Canada worked with Canadian Bar Association clarify and create a Joint Statement on Resuscitative Interventions guideline for use to determine when and how DNR orders are assigned. DNR orders must be discussed by doctors with the patient or patient agents or patient's significant others. Unilateral DNR by medicial professionals can only be used if the patient is in a vegetative state.
- Cardiac arrest
- Power of attorney
- Letting die
- Uniform Rights of the Terminally Ill Act
- Patient Self-Determination Act
- Slow code
- PMID 17174021
- Zoch TW, Desbiens NA, DeStefano F, Stueland DT, Layde PM (July 2000). "Short- and long-term survival after cardiopulmonary resuscitation". Arch. Intern. Med. 160 (13): 1969–73. doi:10.1001/archinte.160.13.1969. PMID 10888971.
- Ehlenbach WJ, Barnato AE, Curtis JR, et al. (July 2009). "Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly". N. Engl. J. Med. 361 (1): 22–31. doi:10.1056/NEJMoa0810245. PMC 2917337. PMID 19571280.
- Alternative to "DNR" Designation: "Allow Natural Death" - Making Sense in the Health Care Industry.
- Vincent JL, Van Vooren JP. [NTBR (Not to Be Resuscitated) in 10 questions]. Rev Med Brux. 2002 Dec;23(6):497-9. French. PubMed PMID 12584945.
- "Mideast med-school camp: divided by conflict, united by profession". The Globe and Mail. August 2009. Retrieved 2009-08-22. "In hospitals in Jordan and Palestine, neither families nor social workers are allowed in the operating room to observe resuscitation, says Mohamad Yousef, a sixth-year medical student from Jordan. There are also no DNRs. “If it was within the law, I would always work to save a patient, even if they didn't want me to,” he says."
- Scottish Government (May 2010). "Do Not Attempt Cardiopulmonary Resuscitation (DNACPR): Integrated Adult Policy". NHS Scotland.
- Eckberg, Evelyn (April 1998). "The continuing ethical dilemma of the do-not-resuscitate order". AORN Journal. Retrieved 2009-08-23. "The right to refuse or terminate medical treatment began evolving in 1976 with the case of Karen Ann Quinlan v New Jersey (70NJ10, 355 A2d, 647 [NJ 1976]). This spawned subsequent cases leading to the use of the DNR order.(4) In 1991, the Patient Self-Determination Act mandated hospitals ensure that a patient's right to make personal health care decisions is upheld. According to the act, a patient has the right to refuse treatment, as well as the right to refuse resuscitative measures.(5) This right usually is accomplished by the use of the DNR order."
- "DO NOT RESUSCITATE – ADVANCE DIRECTIVES FOR EMS Frequently Asked Questions and Answers". State of California Emergency Medical Services Authority. 2007. Retrieved 2009-08-23. "# What if the EMT cannot find the DNR form or evidence of a MedicAlert medallion? Will they withhold resuscitative measures if my family asks them to? No. EMS personnel are taught to proceed with CPR when needed, unless they are absolutely certain that a qualified DNR advance directive exists for that patient. If, after spending a reasonable (very short) amount of time looking for the form or medallion, they do not see it, they will proceed with lifesaving measures."
- "Frequently Asked Questions re: DNR's". New York State Department of Health. 1999-12-30. Retrieved 2009-08-23. "May EMS providers accept living wills or health care proxies? A living will or health care proxy is NOT valid in the prehospital setting"
- Do Not Resuscitate Orders Published by the U.S. National Library of Medicine
- Decisions Relating to Cardiopulmonary Resuscitation Published by the Resuscitation Council (UK)