The document discusses do not resuscitate (DNR) orders, which allow patients to decline life-saving treatments in favor of natural death if they are seriously ill and unable to express their wishes. It outlines the ethical and legal considerations in making DNR decisions, emphasizing communication and documentation among healthcare providers, patients, and their surrogates. Overall, it highlights the importance of respecting patient autonomy and ensuring the decision-making process is well-supported and clear.

1. DO NOT RESUSCITATE
(DNR)
Legal ethics and social aspects.
- By Dhanraj Sethi

2. WHAT ARE ADVANCE DIRECTIVES ?
 Written instruction about future medical care (legal document)
 Only used:
a) If you are seriously ill or injured , and
b) Unable to
 Can be done in two ways :
a. Living will
b. Medical (health care) power of attorney.

3. WHAT IS DNR ?
A Do Not Resuscitate Order, known also as "DNR," is used
by patients who do not wish to receive life-saving
treatment if their heart or lungs ceases to function.
Instead, they opt for a natural death.

4. WHO WRITES DNR ?
A Do Not Attempt Resuscitation (DNAR) order, also known
as Do Not Resuscitate (DNR) order is written by a licensed
physician in consultation with a patient or decision
surrogate maker.
Decision of DNR should be informed and written (DNAR
form)

5. RELEVANCE OF CPR ?
Emergency procedure to attempt to revive patients
suffering from cardiac and/or respiratory arrest
Involves either or all of the following
1. Repeated chest compressions
2. Mouth to mouth breathing or Breathing through
artificial airway.
3. Electric shock/s on chest via defibrillator
4. Injectable drugs.

6. BASIC CARDIOPULMONARY RESUSCITATION

7. WHAT DOES IT PROHIBIT?
DNR prohibits cardiopulmonary resuscitation in a event of
cardiac arrest.
Similar type of form is do not intubate (DNI) which gives
patient rights to not to be intubated in case of respiratory
arrest.(laws are ambiguous around it in India.)

8. WHEN IS DNR RELEVANT ?
 Serious often terminal/debilitating/incurable illness
without prospects of reasonable quality of life even after
revival.
 Should be done in anticipating of an impending
cardiorespiratory arrest, during the current hospitalization
of the patient.

9. HOW IS THE DECISION MADE ?
 SOCIAL ASPECTS –
 Team work and good communication
 COMBINED DECISION MAKING with the help of another
physician, psychologist and hospital administrator.
1. If the treating physician is unsure about the futility of
CPR
2. If there is no consensus between the patient/surrogate
and the physician.

11. ETHICS IN WRITING A DNR ORDER.
Physicians should discuss the resuscitation preferences
with the patients surrogate decision maker.
 Take into account Advance Directive if any.
 Conversation should be documented in patient's notes.
 Final decision should be explicit.
 Indicate who were present during the conversation.
 DNR Form is filled and signed by all parties concerned.

13. LEGAL PAPERWORK
A Copy of the completed DNR form should be attached to
the patient’s case records and integrated with electronic
health records if available.
DNR should be archived for future reference.

14. SUMMARY
DNR is an important clinical decision
 DNR order should ideally be made by a senior clinician.
 Decision should be made in consultation with the patient
/relatives after a clear agreement is reached (patient autonomy
should be respected.)
 Should be well documented.
 Can be revised and reversed.
 It has medico-legal implications.

15. THANK YOU !!