Overview of Do Not Resuscitate Orders

Sometimes a "natural death" is the best option for everyone

A do not resuscitate order (DNR) is a legally binding order signed by a physician at a patient's request. Its purpose is to let medical professionals know you do not want to be resuscitated if you suddenly go into cardiac arrest or stop breathing. This is a common concern of the chronically ill and the elderly. The details of a DNR are usually discussed at the time of admission to a hospital, nursing facility, or hospice program.

A person in a hospital bed
shironosov / istockphoto

What Resuscitation Means

You may have seen TV shows set in hospitals in which a patient in cardiac arrest gets cardiopulmonary resuscitation (CPR), comes back to life, and is back to their old self in no time. In fact, being resuscitated is not so simple and can actually be dangerous in its own right.

Procedures used to resuscitate someone include:

  • Chest compressions: When a person’s heart stops beating, the heart cannot pump blood to the rest of the body, including the brain and lungs. Pushing down on the chest repeatedly can help keep blood flowing throughout the body until heart function is restored.
  • Intubation: When breathing becomes difficult or impossible due to an illness or injury, a patient may be intubated. This involves inserting an endotracheal tube through the mouth and into the airway. The tube is then connected to a ventilator, which pushes air into the lungs.
  • Cardioversion: Cardioversion is used to correct abnormal heart rhythms, including arrhythmias and atrial fibrillation. This may be done using a set of paddles to deliver an electrical shock to the heart, or via a medication.
  • IV medications: Medications that are sometimes used in the case of cardiac arrest include epinephrine, amiodarone, vasopressin, and atropine sulfate.

Respiratory vs Cardiac Arrest

The difference between respiratory and cardiac arrest is that respiratory arrest patients still have a beating heart that is pushing blood around the body. Cardiac arrest patients do not. In both cases, however, a patient is unconscious and not breathing. Respiratory arrest will always lead to cardiac arrest if nothing is done to treat it.

Resuscitation Side Effects

It's important to realize that even if you are successfully resuscitated, you may end up with significant physical injuries as a result. For example, because the chest must be compressed hard and deep enough to pump the blood out of the heart, it can lead to broken ribs, punctured lungs, and possibly a damaged heart.

Those who are resuscitated may also suffer brain damage. This can occur due to lack of blood flow to the brain followed by abnormal cell activity when blood flow to the brain is restored. Generally, the risk increases the longer the duration of CPR.

Resuscitation Survival Rates

Another important thing to think about when considering a DNR is your chances of actually surviving resuscitation.

Statistics on survival vary widely, partly due to the fact that they are many variables involved, including the age and health status of the patient, whether CPR was performed in the hospital or not, and other factors.

A 2021 review looked at research published from 2008 onward that focused on the outcome of CPR in patients age 70 and older following in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA). Survival rates were 28.5% and 11.1%, respectively.

Another Danish study found that 30-day survival among nursing home residents who received CPR after OHCA was 7.7%

Why a DNR May Be the Right Choice

A DNR may be the right choice for someone with a terminal disease, such as advanced cancer, dementia, or a progressing chronic condition. Patients with poor prognoses have a lower likelihood of survival and a higher risk of heart, lung, and brain damage if they do survive a resuscitation attempt.

Types of Orders

A DNR order is sometimes called by other names, though the directive not to resuscitate someone is the same. Two other names for these orders are:

  • No code: In a hospital, an order to withhold resuscitation is sometimes called a "no code" to distinguish it from a "full code" or "code blue," both of which mean every effort should be made at resuscitation.
  • Allow natural death (AND) orders: While a DNR simply states that no attempts should be made to restart breathing or restart the heart if it stops, an AND order ensures that only comfort measures are taken. This would include withholding or discontinuing resuscitation, artificial feedings, fluids, and other measures that would prolong a natural death. These orders are typically used in hospice settings or for terminally ill patients.

DNR Order Rules

Like other complicated medical care in the United States, the application of DNR orders varies from state to state, especially regarding out-of-hospital (ambulance) care. Some states have standardized forms for DNR orders; if the order is not written on that specific form, it cannot be honored. Other states are less regimented, honoring any type of DNR order.

Many states allow emergency responders to follow DNR orders written to other care providers, even if they aren't written on standardized forms. For instance, in New York State, paramedics and emergency medical technicians are usually allowed to follow DNR orders written for the staff of a nursing home. They may also be able to honor orders written for patients getting nursing care at home if the home care nurse has a copy of the DNR order in hand. Each state is different, and municipalities may differ within each state.

Regardless of the format or the venue, DNR orders almost always follow the same general rules to be valid:

  • DNR orders must be written by physicians rather than verbalized. There are exceptions to this rule, such as an emergency medical service physician ordering an ambulance crew to withhold resuscitation via the radio or a registered nurse taking an order from an admitting doctor over the phone. Generally, there are safeguards for these exceptions to make sure the order is validated later.
  • Written DNR orders must include the patient's name; following a DNR order with the wrong patient would be disastrous.
  • DNR orders must be dated. Depending on the state, orders may expire after a certain amount of time or there may be a deadline for the physician to follow up. Even if a DNR order doesn't expire, a particularly old order may prompt caregivers to revisit the decision with patients.
  • The DNR order must be signed by the physician. In those cases where orders were taken by a nurse over the phone, states usually set a deadline for the doctor to physically verify and sign the order.

Making a DNR Work for You

If you opt for a DNR order, here's what you can do to ensure your wishes are respected:

  • Keep the physical order on hand and display it wherever paramedics might find you (or the patient). Make a point to tell them about the order when they arrive. It's a good idea to have more than one copy available and displayed, as well as a copy to accompany the patient to the hospital.
  • If you are traveling, ask your traveling partners to have a copy of your DNR order on them at all times. Keeping a copy on the patient isn't always helpful to rescuers, who are likely to immediately remove a patient's clothing and are very unlikely to look in a wallet or purse.
  • Consider wearing a piece of medical jewelry. MedicAlert Foundation provides jewelry designed specifically for patients with DNR orders. The foundation keeps a copy of the order on file, and can fax it anywhere in the world.

Ethical Complications of DNR Orders

The inconsistent application of DNR orders means some patients may get less than optimal care once providers are aware of the presence of a DNR.

It's important to remember that a DNR order is not an order to withhold all treatment for a patient, but simply an order not to resuscitate a patient.

Because of these issues, for anything other than a terminal diagnosis—like cancer or some end-stage chronic conditions—getting a DNR order may not be the right decision. Discuss the options with your doctor now rather than later, but don't feel pressured to make up your mind about end-of-life decisions.

Frequently Asked Questions

How do you get a do not resuscitate order?

A do not resuscitate order can be obtained in a hospital, nursing home, or hospice program. Most states have standard forms that you can download online.

Who can sign a do not resuscitate order?

A doctor must sign a DNR order with the consent of the patient or the patient's health care proxy.

How do I revoke a do not resuscitate order?

You can change your mind about a DNR order at any time by telling your physician, nursing home staff, or family member to remove it from your file.

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Article Sources
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