Do not resuscitate
|Do not resuscitate|
DNR form used in Virginia
|Synonyms||Do not attempt resuscitation, allow natural death, no code|
Do Not Resuscitate (DNR), also known as no code or allow natural death, is a legal order, written or oral depending on country, to withhold cardiopulmonary resuscitation (CPR) or advanced cardiac life support (ACLS) in case their heart were to stop or they were to stop breathing. Many countries do not allow a DNR order. In most countries which do, the order is made by a doctor. In some countries this is based on the wishes of the patient or health care power of attorney.
US research finds that about 16% of patients who require CPR outside the hospital and 26% of patients who require CPR while in the hospital survive to be discharged from the hospital alive. Patients who are over 80, live in nursing homes, have multiple medical problems, or who have cancer, are slightly less likely to survive.
A DNR is not intended to 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.
Basis for choice
In US hospitals in 2016, 26% of patients who received CPR survived to hospital discharge. 64% of attempts caused a return of spontaneous circulation (ROSC, most recent data are 2014), In 2017 in the US, outside hospitals, 16% of people whose cardiac arrest was witnessed survived to hospital discharge. 43% gained ROSC, and 38% survived to hospital admission.
Even among very sick patients at least 10% survive: A study of CPR in a sample of US hospitals from 2001 to 2010, where overall survival was 19%, found 10% survival among cancer patients, 12% among dialysis patients, 14% over age 80, 15% among blacks, 17% for patients who lived in nursing homes, 19% for patients with heart failure, and 25% for patients with heart monitoring outside the ICU, so there is room for good practices to spread, raising the averages.
An earlier study of Medicare patients in hospitals 1992-2005, where overall survival was 18%, found 13% survival in the poorest neighborhoods, 12% survival over age 90, 15% survival among ages 85–89, and 17% survival among ages 80–84.
A study of King County WA patients who had CPR outside hospitals in 1999-2003, where 34% survived to hospital discharge overall, found that among patients with 4 or more major medical conditions, 18% survived; with 3 major conditions 24% survived, and 33% of those with 2 major medical conditions survived.
Since 2003, widespread cooling of patients after CPR and other improvements have raised survival and reduced mental disabilities.
|Survival to Hospital Discharge||Survival in Group||Average Survival in Study||Group as % of Average||Most Recent Data|
|Nursing home residents||17%||19%||88%||2001-2010|
|Heart Failure patients||19%||19%||99%||2001-2010|
|Diabetes or pacemaker patients||20%||19%||104%||2001-2010|
|Poorest zip codes, average income under $15,000||13%||18%||73%||1992-2005|
|Age over 90||12%||18%||65%||1992-2005|
|4 or more major conditions*||18%||35%||51%||1999-2003|
|3 major conditions*||24%||35%||69%||1999-2003|
|2 major conditions*||33%||35%||94%||1999-2003|
Organ donation is not usually possible after a death with a DNR, but it is after CPR. If the patient dies before discharge, ROSC allows all organs to be considered for donation. If the patient does not achieve ROSC, and CPR continues until an operating room is available, the kidneys and liver can still be considered for donation. 1,000 organs per year in the US are transplanted from patients who had CPR. Donations can be taken from 40% of patients who have ROSC and later become brain dead, and an average of 3 organs are taken from each patient who donates organs. DNR does not usually allow organ donation.
Mental abilities can decline if the brain lacks blood for long, but hospital patients usually keep about the same mental abilities after CPR, based on before and after measurement of US patients' Cerebral-Performance Category (CPC) codes in a 2000-2009 study. 0.6% of patients (2% of survivors) developed severe mental problems after CPR, so that they needed help with daily activities. The study did not say how many of these 0.6% went into comas. Another 0.3% of patients (1% of survivors) developed moderate problems, but could still be independent.
For CPR outside hospitals a Copenhagen study found 3% of patients (21% of survivors) developed moderate mental problems but could still be independent, and 2% (11% of survivors) developed severe mental problems, so they needed help. Two patients out of 2,504 went into comas (0.1% of patients, or 2 out of 419 aurvivors, 0.5%), and the study did not track how long the comas lasted. Most people in comas start to get better in 2–3 weeks. Mental abilities can continue to improve in the six months after discharge, and for long term problems, brains can form new paths to replace damaged areas.
Side effects of CPR vary. The most common is vomiting, which necessitates clearing the mouth so patients do not breathe it in. Broken ribs are present in 3% (2009-12 data) to 8% (1997–99) of those who survive to hospital discharge, and 15% (2009–12) of those who die in the hospital. Those who died had needed longer periods of CPR, which may explain both deaths and fractures. A study in the 1990s found 55% of CPR patients who died before discharge had broken ribs, and a study in the 1960s found 97% did; training and experience levels have improved. A 2004 overview said, "Chest injury is a price worth paying to achieve optimal efficacy of chest compressions. Cautious or faint-hearted chest compression may save bones in the individual case but not the patient’s life." The costal cartilage also breaks in an unknown number of additional cases, which can sound like breaking bones.
POLST documents are the usual place where a DNR is recorded. A disability rights group criticizes the process, saying doctors are trained to offer very limited scenarios with no alternative treatments, and steer patients toward DNR. They also criticize that DNR orders are absolute, without variations for context. The Mayo Clinic found in 2013 that "Most patients with DNR/DNI [do not intubate] orders want CPR and/or intubation in hypothetical clinical scenarios," so the patients had not had enough explanation of the DNR/DNI or did not understand the explanation.
Reductions in other care are not supposed to result from DNR, but they do. Patients with DNR are less likely to get medically appropriate care for a wide range of issues, and die sooner, even from causes unrelated to CPR. Many doctors construe DNR as a goal of not wanting full care, and do not even offer full care. 
After successful CPR, hospitals often discuss putting the patient on DNR, to avoid another resuscitation. Guidelines generally call for a 72-hour wait to see what the prognosis is, but within 12 hours US hospitals put up to 58% of survivors on DNR, with a median of 23% going DNR at this early stage, much earlier than the guideline. The hospitals putting fewest patients on DNR had more successful survival rates, which the researchers suggest shows their better care in general. When CPR happened outside the hospital, hospitals put up to 80% of survivors on DNR within 24 hours, with an average of 32.5%. These patients had less treatment, and almost all died in the hospital. The researchers say families need to expect death if they agree to DNR in the hospital.
Advance directive and living will
Advance directives and living wills are documents written by individuals themselves, so as to state their wishes for care, if they are no longer able to speak for themselves. 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 their wish, as neither an advance directive nor a living will is a legally binding document.
DNR orders in certain situations have been subject to ethical debate. In many institutions it is customary for a patient going to surgery to have their DNR automatically rescinded. Though the rationale for this may be valid, as outcomes from CPR in the operating room are substantially better than general survival outcomes after CPR, the impact on patient autonomy has been debated. It is suggested that facilities engage patients or their decision makers in a 'reconsideration of DNR orders' instead of automatically making a forced decision.
There is accumulating evidence of a racial bias in DNR adoption. A 2014 study of end stage cancer patients found that non-Latino white patients were significantly more likely to have a DNR order (45%) than black (25%) and Latino (20%) patients. The correlation between preferences against life-prolonging care and the increased likelihood of advance care planning is consistent across ethnic groups.
Ethical dilemmas occur when a patient with a DNR attempts suicide and the necessary treatment involves ventilation or CPR. In these cases it has been argued that the principle of beneficence takes precedence over patient autonomy and the DNR can be revoked by the physician. Another dilemma occurs when a medical error happens to a patient with a DNR. If the error is reversible only with CPR or ventilation there is no consensus if resuscitation should take place or not.
There are also ethical concerns around how patients reach the decision to make themselves a DNR. One study found that when questioned in more detail, many patients who were DNR actually would have wanted the excluded interventions depending on the scenario. Most would prefer life saving intubation in the scenario of angioedema which typically resolves in days. One fifth of the DNR patients would want resuscitation for cardiac arrest but to have care withdrawn after a week. It is possible that providers are having a "leading conversation" with patients or mistakenly leaving crucial information out when discussing DNR. One study reported that physicians repeatedly give high intensity care to patients while deciding they themselves would be DNR under similar circumstances.
There is also the ethical issue of discontinuation of an implantable cardioverter defibrillator (ICD) in DNR patients in cases of medical futility. A large survey of Electrophysiology practitioners, the heart specialists who implant pacemakers and ICD's noted that the practitioners felt that deactivating an ICD was not ethically distinct from withholding CPR thus consistent with DNR. Most felt that deactivating a pacemaker was a separate issue and could not be broadly ethically endorsed. Pacemakers were felt to be unique devices, or ethically taking a role of "keeping a patient alive" like dialysis.
DNR and Do Not Resuscitate are common terms in the United States, Canada, New Zealand and the United Kingdom. This 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. Hospitals sometimes use the expression no code, which refers to the jargon term code, short for Code Blue, an alert a hospital's resuscitation team.
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 or family that an attempt at resuscitation will be successful.
Since the term DNR implies the omission of action, and therefore "giving up", a few authors 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 not punctuated, e.g., DNR rather than D.N.R.
Resuscitation orders, or lack thereof, can also be referred to in the United States as a part of Physician Orders for Life-Sustaining Treatment (POLST), Medical Orders for Life-Sustaining Treatment (MOLST), Physician's Orders on Scope of Treatment (POST) or Transportable Physician Orders for Patient Preferences (TPOPP) orders, typically created with input from next of kin when the patient or client is not able to communicate their wishes.
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.
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.
A 2016 paper reports a survey of doctors in numerous countries, asking "how often do you discuss decisions about resuscitation with patients and/or their family?" and "How do you communicate these decisions to other doctors in your institution?" Some countries had multiple respondents, who did not always act the same, as shown below. There was also a question "Does national guidance exist for making resuscitation decisions in your country?" but the concept of "guidance" had no consistent definition, For example in the USA, four respondents said Yes, and two said No.
|Country||Discuss with Patient or Family||Tell Other Doctors the Decision|
|Australia||Most, Half||Oral+Notes+Pre-printed (2), Notes|
|Canada||Always, Most||Oral+Notes, Oral+Notes+Electronic, Notes+Pre-printed|
|Hong Kong||Always, Half||Notes+Pre-printed, Oral+Notes+Pre-printed|
|India||Always||Notes, Oral, Oral+Notes|
|Ireland||Most, Rarely||Notes (2)|
|Israel||Most, Half||Oral+Notes (2) Notes|
|Japan||Most, Half||Oral, Notes,|
|Norway||Always, Rarely||Oral, Notes+Electronic|
|Poland||Always, Most||Oral+Notes, Notes+Pre-printed|
|Saudi Arabia||Always, Most||Pre-printed, Notes+Electronic, Oral|
|Singapore||Always, Most, Half||Pre-printed (2), Oral+Notes+Pre-printed, Oral+Notes+Electronic, Oral+Pre-printed|
|Spain||Always, Most||Pre-printed, Oral+Notes+Electronic, Oral+Notes+Pre-printed|
|Switzerland||Most, Half||Oral+Notes+Pre-printed, Oral+Notes+Other|
|Taiwan||Half, Rarely||Notes+Pre-printed+Other, Oral|
|USA||Always, Most||Notes, Electronic, Oral+Electronic, Oral+Notes+Electronic, Oral+Notes+Pre-printed+Electronic|
DNRs are not recognized by Jordan. Physicians attempt to resuscitate all patients regardless of individual or familial wishes. The UAE have laws forcing healthcare staff to resuscitate a patient even if the patient has a DNR or does not wish to live. There are penalties for breaching the laws. In Saudi Arabia patients cannot legally sign a DNR, but DNR accepted by order of primary physician in case of terminally ill patients. 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, CPR is presumed in the event of a cardiac arrest unless a do not resuscitate order is in place. If they have capacity as defined under the Mental Capacity Act 2005 the patient may decline resuscitation, however any discussion is not in reference to consent to resuscitation and instead should be an explanation. Patients may also specify their wishes and/or devolve their decision-making to a proxy using an advance directive, which are commonly referred to as 'Living Wills'. Patients and relatives cannot demand treatment (including CPR) which the doctor believes is futile and 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. If they lack capacity relatives will often be asked for their opinion out of respect.
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 may not be accepted by EMS as legally valid forms. If a patient has a living will that specifies the patient requests of DNR but does not have a properly filled out state-sponsored form that is co-signed by a physician, EMS may 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 advance directive that results in a DNR/DNI code status in the hospital.
In the United States, cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) will not be performed if a valid written "DNR" order is present. Many 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 properly 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 the Canadian Bar Association to 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 medical professionals can only be used if the patient is in a vegetative state.
In Australia, Do Not Resuscitate orders are covered by legislation on a state-by-state basis.
In Victoria, a Refusal of Medical Treatment certificate is a legal means to refuse medical treatments of current medical conditions. It does not apply to palliative care (reasonable pain relief; food and drink). An Advanced Care Directive legally defines the medical treatments that a person may choose to receive (or not to receive) in various defined circumstances. It can be used to refuse resuscitation, so as avoid needless suffering.
In NSW, a Resuscitation Plan is a medically authorised order to use or withhold resuscitation measures, and which documents other aspects of treatment relevant at end of life. Such plans are only valid for patients of a doctor who is a NSW Health staff member. The plan allows for the refusal of any and all life-sustaining treatments, the advance refusal for a time of future incapacity, and the decision to move to purely palliative care.
DNRs are not recognized by Italy. Physicians must attempt to resuscitate all patients regardless of individual or familial wishes. Italian laws force healthcare staff to resuscitate a patient even if the patient has a DNR or does not wish to live. There are jail penalties (from 6 to 15 years) for healthcare staff breaching this law, e.g. "omicidio del consenziente".[better source needed] Therefore in Italy a signed DNR has no legal value.
In Taiwan, patients sign their own DNR orders, and are required to do so to receive hospice care.
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Part 3: Ethical Issues – ECC Guidelines, Timing of Prognostication in Post–Cardiac Arrest Adults
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- Scottish Government (May 2010). "Do Not Attempt Cardiopulmonary Resuscitation (DNACPR): Integrated Adult Policy" (PDF). NHS Scotland.
- Eckberg E (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. Archived from the original on 2009-08-23. 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". Princess Margaret Hospital d. Archived from the original on 2014-07-15. Retrieved 2012-12-05.
- "Respect for the right to choose - Resources". Dying with dignity, Victoria. 2017. Retrieved 2017-06-14.
- "Using resuscitation plans in end of life decisions" (PDF). Government of New South Wales Health Department. 2014-09-08. Retrieved 2017-06-14.
- it:Omicidio del consenziente (ordinamento penale italiano)
- Fan SY, Wang YW, Lin IM (October 2018). "Allow natural death versus do-not-resuscitate: titles, information contents, outcomes, and the considerations related to do-not-resuscitate decision". BMC Palliative Care. 17 (1): 114. doi:10.1186/s12904-018-0367-4. PMC 6180419. PMID 30305068.
- "Do Not Resuscitate Orders". MedlinePlus. U.S. National Library of Medicine.
- "Decisions Relating to Cardiopulmonary Resuscitation". Resuscitation Council (UK).