Do Not Resuscitate (DNR) Orders
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There is a lot of confusion around Do Not Resuscitate (DNR) orders. This is a medical order that advises healthcare professionals not to attempt a cardiopulmonary resuscitation (CPR) on a person who has suffered a cardiac arrest. Healthcare workers, paramedics, and EMTs are required to attempt CPR on all people who have suffered a cardiac arrest unless a person has a DNR order. This DNR order must be available in the moment or else the assumption is that the person does not have one. This lecture will cover DNR orders and how to complete one.
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Do Not Resuscitate (DNR) Orders
- 1. Do Not Resuscitate (DNR) Order Eleanor Tanno, M.D. www.advancedirectivemd.com Osher Lifelong Learning Institute- American University July 2022
- 2. What does it mean to be Do Not Resuscitate (DNR)? • The more informative question is, what does it look like to be resuscitated? • Video of CPR (good outcome) https://www.youtube.com/watch?v=yUV2oGDGZn0
- 3. Review of Cardiopulmonary Resuscitation (CPR) • A resuscitation is attempted when there is no heart beat and the breathing is absent or irregular • During CPR, regular compressions are applied to the chest to manually pump blood from the heart to the body. • Electric shocks are administered at regular intervals to try to “jump start” the heart. • During a resuscitation, breathing tubes may be inserted into you to open the airway and medications may be used to control your heart.
- 4. What is the success rate of a resuscitation? • Success is defined as survival to leave the hospital • Community setting - 10% • In-Hospital setting - 25% • The odds are better depending on their age, overall health, and the underlying reason for the arrest
- 5. What is a Do Not Resuscitate (DNR) order? • medical order, signed by a physician (or nurse practitioner in some states), that instructs healthcare workers NOT to resuscitate a person who has had a cardiac arrest. • The order must be chosen by the patient or, if applicable, their medical Power of Attorney (POA) • If a person does not have a DNR order, by default, medical personnel, including paramedics, will always attempt a resuscitation.
- 6. Who should have a DNR order? • Personal decision, based on current health
- 7. How do I make a DNR order? • You create a DNR order with your physician, or nurse practitioner in some states. • Schedule an appointment just to have this discussion and ask all your questions. • Accomplished by signing the appropriate state form (MOLST). • Some states call this form a MOST/POST/POLST
- 8. DNR Order on MOLST • Let’s look at the DNR order on the MOLST form
- 9. Where to store a DNR order? • Copies to: • Yourself – readily available in your home in case paramedics are called • Consider medical bracelet/tag • Your doctor • Your medical power of attorney • keep a copy with your estate documents • Some states have a database where you can upload your advance directive and DNR order • Always bring a copy of your DNR order with you when you go to the hospital.
- 10. How do paramedics and other healthcare workers know whether someone has a DNR order? • At the time of the arrest, the healthcare workers need to be presented with a signed DNR order to NOT attempt CPR. • all patients admitted to the hospital are asked whether they have a DNR order and it is noted in their chart. • For people who desire for their DNR order to be honored in a community setting (at their home, etc.), they must have the order prominently displayed so that it is known they have such an order. • Some patients will order a DNR medical bracelet. • A tattoo cannot act as a DNR order.
- 12. What if I want to revoke my DNR order? • Anytime! • Just tear it up or write “VOID” over it. • Be sure all the copies are also destroyed and you update your medical power of attorney and other key people in your life.
- 13. Can my POA/family change my DNR order? • Generally, doctors try to follow the patient’s wishes • Your family can revoke your DNR order, but if doctors really feel this is not your wish and not in your best interest, they can escalate the decision to a hospital Ethics Committee for further discussion.
- 14. Questions? • Eleanor Tanno, M.D. • www.advancedirectivemd.com
Editor's Notes
- https://www.youtube.com/watch?v=yUV2oGDGZn0 Video of CPR 3 MINUTES, happy ending Last week, we reviewed CPR. We saw the video of the man who collapsed in his office. If you recall, the paramedics were called, CPR was started within minutes. CPR was started because his heart suddenly stopped. They used chest compressions and shocks. They were able to restart his heart and take him to the hospital. In the hospital, the doctors would need to figure out why his heart stopped and treat the underlying condition. This man was very lucky – his coworkers found him right away and CPR was started within minutes. The time between the heart stopping and brain damage is about 5 minutes so timing is key.
- Unfortunately, CPR is not as effective in real life as portrayed in the movies. Even if the heart is restarted, the patient remains very unstable and has a high risk of dying within the next few days.
- Depends on underlying health If someone is generally in poor health (end stage cancer) or has a very poor quality of life (dementia in a nursing home, severe chronic pain, etc.), they may desire a natural death when it happens. Many people reach a point where they may say, if I should pass away, please leave me dead. However, if someone is generally in very good health, they may likely want a resuscitation attempted. Just remember, that recovery after CPR is generally unlikely – 10-25% Many times patients will say to me, if I can recover, I want CPR attempted. As we have learned, the decision to start CPR is emergent and often the underlying reason for the cardiac arrest is unknown until they patient is transported to the hospital.
- https://marylandmolst.org/docs/MOLST%20MM3%202013%20FINAL%20PROPOSED%2072613%20POSTED%2021714.pdf
- Paramedics will not spend more than a few moments looking for the form so it needs to be somewhere extremely visible such as posted in the front entrance or on the fridge. They will not look in drawers or in a safe.
- Tattoos cannot be DNR orders