A DNR order — short for Do Not Resuscitate — is a medical order that instructs healthcare providers not to perform cardiopulmonary resuscitation if a patient’s heart stops beating or they stop breathing. It is one of the most important and most misunderstood documents in end of life care planning.
What a DNR order does
A DNR order tells doctors, nurses, and emergency medical personnel not to attempt CPR if a patient experiences cardiac arrest or respiratory failure. Without a DNR order healthcare providers are generally required to attempt resuscitation in an emergency situation regardless of the patient’s age or medical condition.
A DNR order does not mean that all medical treatment stops. It only applies to resuscitation efforts. A patient with a DNR order still receives all other medical care including medications, pain management, treatment for infections, and other interventions aimed at comfort and quality of life.
What CPR involves
Understanding what CPR actually involves can help people make more informed decisions about DNR orders. Cardiopulmonary resuscitation can include:
- Chest compressions which can be forceful enough to break ribs especially in older or frail patients
- Electric shocks to the heart using a defibrillator
- Insertion of a breathing tube into the airway
- Mechanical ventilation to breathe for the patient
- Medications to stimulate heart activity
For healthy people who experience sudden cardiac arrest CPR can be lifesaving. However for people who are seriously ill, very frail, or at the end of life CPR is often not effective and can cause significant pain, injury, and distress in the final moments of life.
Who should consider a DNR order
A DNR order is not appropriate for everyone. It is most commonly considered by people who:
- Have a terminal illness with a limited life expectancy
- Are in the advanced stages of a serious chronic illness such as heart failure, cancer, or dementia
- Are elderly and frail and for whom CPR would be unlikely to succeed or would cause significant harm
- Have clearly expressed that they do not want aggressive life-prolonging interventions
- Want to focus on comfort and quality of life rather than life-prolonging treatment
A DNR order is a deeply personal decision that should be made in consultation with a physician who understands the patient’s medical condition and prognosis.
DNR order vs advance directive
A DNR order and an advance directive are related but different documents:
- An advance directive — also called a living will — is a legal document that describes a person’s general wishes regarding medical treatment. It is created by the patient in advance and takes effect when the patient can no longer communicate.
- A DNR order is a specific medical order signed by a physician that instructs healthcare providers not to perform CPR. It is based on the patient’s wishes but must be signed by a doctor to be valid.
Having an advance directive that states you do not want CPR does not automatically create a DNR order. You or your healthcare agent must work with your physician to have a formal DNR order written and placed in your medical records.
Types of DNR orders
There are different types of DNR orders that apply in different settings:
- In-hospital DNR — a DNR order that applies within a hospital setting. It is placed in the patient’s hospital chart and instructs hospital staff not to perform CPR.
- Out-of-hospital DNR — also called a prehospital DNR or portable DNR, this order applies outside of a hospital setting such as at home, in an assisted living facility, or in a nursing home. It instructs emergency medical personnel not to perform CPR if called to the scene.
- POLST form — Physician Orders for Life-Sustaining Treatment, also called MOLST or MOST in some states, is a more comprehensive medical order form that addresses not only CPR but also other life-sustaining treatments such as mechanical ventilation and artificial nutrition. It is designed to travel with the patient across care settings.
How to get a DNR order
To obtain a DNR order:
- Have a conversation with your physician about your medical condition, prognosis, and wishes regarding resuscitation
- Your physician writes the DNR order and signs it
- The order is placed in your medical records
- If you want an out-of-hospital DNR make sure a copy is kept at home in an easily accessible location — not in a drawer or safe deposit box
In many states out-of-hospital DNR orders must be on a specific state-approved form. Your physician or hospital social worker can provide the correct form for your state.
Where to keep a DNR order
A DNR order is only effective if emergency responders can find it quickly. Recommended places to keep a DNR order at home include:
- On the refrigerator door — emergency medical personnel are trained to look there
- Near the patient’s bed
- In a medical alert bracelet or wallet card that references the DNR
- With the patient’s other important medical documents
Make sure your family members, caregivers, and healthcare agent know where the DNR order is kept.
Can a DNR order be revoked
Yes — a DNR order can be revoked at any time by the patient or in some cases by the patient’s healthcare agent. To revoke a DNR order notify your physician and make sure the order is removed from your medical records. Destroy any physical copies of the order.
Talking to family members about a DNR order
Conversations about DNR orders can be emotionally difficult but they are important. Family members who are unaware of a loved one’s DNR order may call 911 in an emergency and request resuscitation which can create confusion and distress. Having an open conversation with family members about your wishes and the existence of a DNR order can prevent misunderstandings and ensure your wishes are honored.
DNR orders and hospice care
DNR orders are common among people receiving hospice care. Hospice is a type of care focused on comfort and quality of life for people with a terminal illness and a life expectancy of six months or less. Most people entering hospice care choose to have a DNR order as part of their overall goal of avoiding aggressive life-prolonging interventions.
Key terms to know
- DNR order — a medical order instructing healthcare providers not to perform CPR
- CPR — cardiopulmonary resuscitation, a set of emergency procedures used to restore heart and breathing function
- Advance directive — a legal document describing a person’s wishes regarding medical treatment
- POLST — Physician Orders for Life-Sustaining Treatment, a comprehensive medical order form addressing multiple life-sustaining treatments
- Out-of-hospital DNR — a DNR order that applies outside of a hospital setting
- Hospice care — care focused on comfort and quality of life for people with a terminal illness
- Healthcare agent — the person named in a healthcare power of attorney to make medical decisions on behalf of the patient
Sources
- National Institute on Aging — End of Life Care
- American Bar Association — Public Resources
- Centers for Medicare and Medicaid Services
- USA.gov
This article is for general informational purposes only and does not constitute legal or medical advice. DNR order requirements vary by state. Consult a physician or licensed healthcare provider for guidance specific to your situation.