The general public may not always understand or may be confused about Do Not Resuscitate (DNR) orders and their ramifications. The first and most important thing to know and understand is that a DNR is a legal medical order that must be signed by a physician or other authorized health care professional. It then serves to inform all health care providers to withhold Cardiopulmonary Resuscitation (CPR) or any other life-saving procedures on someone whose heart stops beating or who stops breathing.
DNR orders came into being years after CPR was developed when patient autonomy was being promoted. It was intended to give more health care choices to the individual. It was also meant to prevent CPR from being performed on a person when it was determined to be harmful or at the very least determined it would provide no benefit. For example, let’s say a person is very near death from cancer. In that case it would be reasonable to have a signed DNR in order to allow that individual to die more naturally without aggressive, possibly harmful, intervention like CPR. On the other hand say a healthy person has a signed DNR, gets hit by a car and rendered unconscious and unable to breathe. No measures may be given by health care personnel that might save his or her life. Since no one has a crystal ball to see into the future, rejecting medical care by having a DNR order when you’re healthy and not near death could actually put your life in danger.
How might it happen that choosing to have a DNR order in your medical record could ultimately cost you your life? Let’s suppose you have signed a POLST (Physician Orders for Life Sustaining Treatment) document. This is also a legally binding medical order intended to follow you wherever you may be so that medical personnel will know your health care wishes. Signing a POLST is generally recommended for end of life medical care choices, but in reality can be downloaded from the Internet, signed and authorized at any time of life. On the form there are boxes to check to indicate the type of care wanted or not wanted. The first box (A) says Do Not Attempt Resuscitation/DNR. If you have this box checked, you will NOT be given CPR in an emergency– no matter your age or state of health at the time.
As another example, you are about to go into the hospital for a surgical procedure. It would not be uncommon for you to be asked whether you’d like to have a DNR order in place. Before you agree, it might be helpful to know of a study done that examined post-surgery results of patients who signed a DNR before surgery. Whatever type of procedure was to be done, or your health status before surgery, it was found that those who had a DNR order fared worse than those without one. Those patients with a DNR were also more likely to suffer serious complications and have longer hospital stays. These complications might be explained by saying that someone with a DNR order is probably sicker to begin with. “They start out sicker, that’s true,” says one of the researchers of the study, Sanziana Roman, MD, associate professor of surgery at Yale University. “But if we take that into account and take it out of the equation, we still found the DNR on its own was an independent risk factor for death.” The study also raised the question of whether having a DNR might change the way patients are treated. “If I were a patient, I might worry from this study that having a DNR on my chart might lead to less aggressive treatment,” said Clarence Braddock, MD, MPH professor of medicine and associate dean of medical education at Stanford School of Medicine.1 In fairness, it should be mentioned that there are physicians who take exception to that study. There are others who believe a DNR should be suspended during surgery.
A patient should always be consulted before a DNR order is written. If the patient is unable to make the decision, then it should be made in consultation with the surrogate decision maker. Making the decision to have a DNR in place can be difficult at times; at other times less so. Precise communication between the doctor and the decision maker is extremely important to ensure that the order is properly understood and communicated as to what to expect if CPR is initiated. At times CPR can be an invasive procedure. If someone is dying from an incurable condition it would be crucial to know if CPR will it be of any benefit or not. The question is: would such aggressive efforts actually be harmful? These are matters to be carefully considered before a signing a DNR.
A DNR order can be a separate document or may be included as part of an advance directive. Either way it could be dangerous if you are a relatively young, relatively healthy person.
Research has shown that a DNR order not only can be confusing to patients, but also to physicians. They can be misinterpreted as to a patient’s true preference, applied inconsistently, or conflict with hospital policies, themselves often unclear or differing from state regulations. Moreover many health care providers mistakenly assume that a DNR on a patient’s chart means the patient is dying. Several studies have demonstrated that it’s not uncommon for a patient with a DNR order in place to receive less aggressive treatment. Writing in a medical journal, an experienced RN cautions oncology nurses to protect the safety of their patients by “ensuring that DNR orders are not over-interpreted so that important kinds of care are not wrongly withheld from patients who have a DNR.” 2
This exact scenario was the point of an article in Investor’s Business Daily by Betsy McCauley in which she stated “New research shows having those three letters — DNR — on your chart could put you on course to getting less medical and nursing care throughout your stay. Fewer MRIs and CT scans, fewer medications, even fewer bedside visits from doctors, according to the Journal of Patient Safety.” 3
It is therefore essential that a person never be pressured into making the decision to have a DNR form executed. This is especially true when being admitted into a health care facility.
The important decision of whether or not to have a DNR order is ideally made in the last days of life. If you are in that situation, and your doctor has not brought up the subject, it might be time to initiate that talk. A frank discussion with him or her about the risks and benefits of having a DNR in your individual case would be helpful in deciding what to do. You may also want to consult the family in the decision. While debating the issue, ethical questions may arise, and that is where a member of the clergy could be of help.
NOTES
1. Warner, Jennifer, DNR Orders May Affect Surgical Outcomes, WebMD.com, April 18, 2011.
2. Glenn, David G., RN, MS, Preventing Safety Hazards Associated With Do-Not-Resuscitate Orders, Clinical Journal of OncologyNursing, Vol. 19, no. 6, p.667.
3. McCaughey, Betsy, Do Not Sign A DNR Before You Read This, Investor’s Business Daily, March 28, 2018
Germaine Wensley, RN, is a member of the Scholl Institute of Bioethics executive board, a founder, past president and editor of LifeScenes of California Nurses for Ethical Standards, and a Charter member of Los Angeles Archdiocese Commission on Life Issues (now retired).