Do not resuscitate
Encyclopedia
In medicine
, a "do not resuscitate" or "DNR" is a legal order written either in the hospital or on a legal form to respect the wishes of a patient to not undergo CPR or advanced cardiac life support
(ACLS) if their heart were to stop or they were to stop breathing. This 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 ACLS outside the hospital and only 15% of patients who require ACLS while in the hospital survive
In medicine
, a "do not resuscitate" or "DNR" is a legal order written either in the hospital or on a legal form to respect the wishes of a patient to not undergo CPR or advanced cardiac life support
(ACLS) if their heart were to stop or they were to stop breathing. This 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 ACLS outside the hospital and only 15% of patients who require ACLS while in the hospital survive
In medicine
, a "do not resuscitate" or "DNR" is a legal order written either in the hospital or on a legal form to respect the wishes of a patient to not undergo CPR or advanced cardiac life support
(ACLS) if their heart were to stop or they were to stop breathing. This 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 ACLS outside the hospital and only 15% of patients who require ACLS while in the hospital survive PMID 17174021 PMID 10888971 . Patients who are elderly, are living in nursing homes, have multiple medical problems, or who have advanced cancer are much less likely to survive. PMID 19571280
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.
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. 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. This is a little known fact to many patients and primary care physicians that can cause patients to receive treatments they do not want, and this law is currently being evaluated for a constitutional challenge.
. 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.Alternative to "DNR" Designation: "Allow Natural Death" - Making Sense in the Health Care Industry. 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..
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.
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.
, 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 doctors' 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. 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'.
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.
Medicine
Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....
, a "do not resuscitate" or "DNR" is a legal order written either in the hospital or on a legal form to respect the wishes of a patient to not undergo CPR or advanced cardiac life support
Advanced cardiac life support
Advanced cardiac life support or Advanced Cardiovascular Life Support refers to a set of clinical interventions for the urgent treatment of cardiac arrest and other life threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.Extensive medical knowledge...
(ACLS) if their heart were to stop or they were to stop breathing. This request is usually made by the patient or health care power of attorney
Power of attorney
A power of attorney or letter of attorney is a written authorization to represent or act on another's behalf in private affairs, business, or some other legal matter...
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 ACLS outside the hospital and only 15% of patients who require ACLS while in the hospital survive
In medicine
Medicine
Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....
, a "do not resuscitate" or "DNR" is a legal order written either in the hospital or on a legal form to respect the wishes of a patient to not undergo CPR or advanced cardiac life support
Advanced cardiac life support
Advanced cardiac life support or Advanced Cardiovascular Life Support refers to a set of clinical interventions for the urgent treatment of cardiac arrest and other life threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.Extensive medical knowledge...
(ACLS) if their heart were to stop or they were to stop breathing. This request is usually made by the patient or health care power of attorney
Power of attorney
A power of attorney or letter of attorney is a written authorization to represent or act on another's behalf in private affairs, business, or some other legal matter...
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 ACLS outside the hospital and only 15% of patients who require ACLS while in the hospital survive
In medicine
Medicine
Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....
, a "do not resuscitate" or "DNR" is a legal order written either in the hospital or on a legal form to respect the wishes of a patient to not undergo CPR or advanced cardiac life support
Advanced cardiac life support
Advanced cardiac life support or Advanced Cardiovascular Life Support refers to a set of clinical interventions for the urgent treatment of cardiac arrest and other life threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.Extensive medical knowledge...
(ACLS) if their heart were to stop or they were to stop breathing. This request is usually made by the patient or health care power of attorney
Power of attorney
A power of attorney or letter of attorney is a written authorization to represent or act on another's behalf in private affairs, business, or some other legal matter...
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 ACLS outside the hospital and only 15% of patients who require ACLS while in the hospital survive PMID 17174021 PMID 10888971 . Patients who are elderly, are living in nursing homes, have multiple medical problems, or who have advanced cancer are much less likely to survive. PMID 19571280
A DNR does not affect any treatment other than that which would require intubation
Tracheal intubation
Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic or rubber tube into the trachea to maintain an open airway or to serve as a conduit through which to administer certain drugs...
or CPR. Patients who are DNR can continue to get chemotherapy, antibiotics, dialysis, or any other appropriate treatments.
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. 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
Emergency medical services
Emergency medical services are a type of emergency service dedicated to providing out-of-hospital acute medical care and/or transport to definitive care, to patients with illnesses and injuries which the patient, or the medical practitioner, believes constitutes a medical emergency...
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. This is a little known fact to many patients and primary care physicians that can cause patients to receive treatments they do not want, and this law is currently being evaluated for a constitutional challenge.
Alternative names
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 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 intubationTracheal intubation
Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic or rubber tube into the trachea to maintain an open airway or to serve as a conduit through which to administer certain drugs...
. 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.Alternative to "DNR" Designation: "Allow Natural Death" - Making Sense in the Health Care Industry. 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..
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
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 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.
Middle East
DNRs are not recognized by Jordan but in Israel, it is possible to sign a DNR form as long as the patient is dying and aware of his actions. Physicians attempt to resuscitate all patients regardless of individual or familial wishes.United Kingdom
In England, for DNR as for any medical treatment, by default only the patient can give informed consentInformed consent
Informed consent is a phrase often used in law to indicate that the consent a person gives meets certain minimum standards. As a literal matter, in the absence of fraud, it is redundant. An informed consent can be said to have been given based upon a clear appreciation and understanding of the...
, if they have capacity as defined under the Mental Capacity Act 2005
Mental Capacity Act 2005
The Mental Capacity Act 2005 is an Act of the Parliament of the United Kingdom. Its primary purpose is to provide a legal framework for acting and making decisions on behalf of adults who lack the capacity to make particular decisions for themselves....
; 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 doctors' 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. 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'.
United States
The DNR decision by patients was first litigated in 1976 in In re Quinlan. The New Jersey Supreme Court upheld the right of Quinlan's parents to order her removal from artificial ventilation. In 1991 Congress passed into law the Patient Self-Determination ActPatient Self-Determination Act
The Patient Self-Determination Act was passed by the U.S. Congress in 1990 as an amendment to the Omnibus Budget Reconciliation Act of 1990...
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
Missouri is a US state located in the Midwestern United States, bordered by Iowa, Illinois, Kentucky, Tennessee, Arkansas, Oklahoma, Kansas and Nebraska. With a 2010 population of 5,988,927, Missouri is the 18th most populous state in the nation and the fifth most populous in the Midwest. It...
. 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
Cardiopulmonary resuscitation
Cardiopulmonary resuscitation is an emergency procedure which is performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person in cardiac arrest. It is indicated in those who are unresponsive...
(CPR) and advanced cardiac life support
Advanced cardiac life support
Advanced cardiac life support or Advanced Cardiovascular Life Support refers to a set of clinical interventions for the urgent treatment of cardiac arrest and other life threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.Extensive medical knowledge...
(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
Health care proxy
A Health Care Proxy is an instrument that allows a patient to appoint an agent to make health care decisions in the event that the primary individual is incapable of executing such decisions. Once the document is drafted, the primary individual continues to be allowed to make health care decisions...
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.
See also
- Cardiac arrestCardiac arrestCardiac arrest, is the cessation of normal circulation of the blood due to failure of the heart to contract effectively...
- Power of attorneyPower of attorneyA power of attorney or letter of attorney is a written authorization to represent or act on another's behalf in private affairs, business, or some other legal matter...
- EuthanasiaEuthanasiaEuthanasia refers to the practice of intentionally ending a life in order to relieve pain and suffering....
- Uniform Rights of the Terminally Ill ActUniform Rights of the Terminally Ill ActThe Uniform Rights of the Terminally Ill Act , has been recommended as a Uniform Act in the United States, and subsequently been passed by many states. The law allows a person to declare a living will specifying that, if the situation arises, he or she does not wish to be kept alive through life...
- Patient Self-Determination ActPatient Self-Determination ActThe Patient Self-Determination Act was passed by the U.S. Congress in 1990 as an amendment to the Omnibus Budget Reconciliation Act of 1990...
External links
- Right To die Debate on Opposing Views
- Example of a DNR form
- Decisions Relating to Cardiopulmonary Resuscitation Published by the Resuscitation Council (UK)
- DNRhu | Online Donor Magazine(HU)
- Example of a DNR dogtag