Do not resuscitate

A do-not-resuscitate order (DNR), also known as Do Not Attempt Resuscitation (DNAR), Do Not Attempt Cardiopulmonary Resuscitation (DNACPR), no code or allow natural death, is a medical order, written or oral depending on country, indicating that a person should not receive cardiopulmonary resuscitation (CPR) if that person's heart stops beating. Sometimes these decisions and the relevant documents also encompass decisions around other critical or life-prolonging medical interventions. The legal status and processes surrounding DNR orders vary from country to country. Most commonly, the order is placed by a physician based on a combination of medical judgement and patient involvement.

Basis for choice

Interviews with 26 DNR patients and 16 full code patients in Toronto in 2006-9 suggest that the decision to choose do-not-resuscitate status was based on personal factors including health and lifestyle; relational factors (to family or to society as a whole); and philosophical factors.
Audio recordings of 19 discussions about DNR status between doctors and patients in 2 US hospitals (San Francisco and Durham) in 2008-9 found that patients "mentioned risks, benefits, and outcomes of CPR," and doctors "explored preferences for short- versus long-term use of life-sustaining therapy." A Canadian article (Diana Ginn and David Zitner, Canadian Family Physician, 1995 CPR Not for All Terminally Ill Patients) suggests that it is inappropriate to offer CPR when the clinician knows the patient has a terminal illness and that CPR will be futile.

Outcomes of CPR

When medical institutions explain DNR, they describe survival from CPR, in order to address patients' concerns about outcomes. After CPR in hospitals in 2017, 7,000 patients survived to leave the hospital alive, out of 26,000 CPR attempts, or 26%. After CPR outside hospitals in 2018, 8,000 patients survived to leave the hospital alive, out of 80,000 CPR attempts, or 10%. Success was 21% in a public setting, where someone was more likely to see the person collapse and give help than in a home. Success was 35% when bystanders used an Automated external defibrillator (AED), outside health facilities and nursing homes.

In information on DNR, medical institutions compare survival for patients with multiple chronic illnesses;
patients with heart, lung or kidney disease; liver disease;
widespread cancer
or infection;
and residents of nursing homes.
Research shows that CPR survival is the same as the average CPR survival rate, or nearly so, for patients with multiple chronic illnesses,
or diabetes, heart or lung diseases.
Survival is about half as good as the average rate, for patients with kidney or liver disease, or widespread cancer
or infection.

For people who live in nursing homes, survival after CPR is about half to three quarters of the average rate.
In health facilities and nursing homes where AEDs are available and used, survival rates are twice as high as the average survival found in nursing homes overall. Few nursing homes have AEDs.

Research on 26,000 patients found similarities in the health situations of patients with and without DNRs. For each of 10 levels of illness, from healthiest to sickest, 7% to 36% of patients had DNR orders; the rest had full code.

Risks

As noted above, patients considering DNR mention the risks of CPR. Physical injuries, such as broken bones, affect 13% of CPR patients, and an unknown additional number have broken cartilage which can sound like breaking bones.

Mental problems affect some patients, both before and after CPR. After CPR, up to 1 more person, among each 100 survivors, is in a coma than before CPR (and most people come out of comas).
5 to 10 more people, of each 100 survivors, need more help with daily life than they did before CPR.
5 to 21 more people, of each 100 survivors, decline mentally, but stay independent.The ranges given in the text above represent outcomes ''inside'' and ''outside'' of hospitals:
* ''In US hospitals'' a study of 12,500 survivors after CPR, 2000-2009, found: 1% more survivors of CPR were in comas than before CPR (3% before, 4% after), 5% more survivors were dependent on other people, and 5% more had moderate mental problems but were still independent. ''''
* ''Outside hospitals'', half a percent more survivors were in comas after CPR (0.5% before, 1% after), 10% more survivors were dependent on other people because of mental problems, and 21% more had moderate mental problems which still let them stay independent. This study covered 419 survivors of CPR in Copenhagen in 2007-2011. and works cited.

Organ donation

Organ donation is possible after CPR, but not usually after a death with a DNR. If CPR does not revive the patient, and continues until an operating room is available, kidneys and liver can be considered for donation. US Guidelines endorse organ donation, "Patients who do not have ROSC eturn of spontaneous circulationafter resuscitation efforts and who would otherwise have termination of efforts may be considered candidates for kidney or liver donation in settings where programs exist." European guidelines encourage donation, "After stopping CPR, the possibility of ongoing support of the circulation and transport to a dedicated centre in perspective of organ donation should be considered." CPR revives 64% of patients in hospitals and 43% outside (ROSC), which gives families a chance to say goodbye, and all organs can be considered for donation, "We recommend that all patients who are resuscitated from cardiac arrest but who subsequently progress to death or brain death be evaluated for organ donation."

1,000 organs per year in the US are transplanted from patients who had CPR. Donations can be taken from 40% of patients who have ROSC and later become brain dead, and an average of 3 organs are taken from each patient who donates organs. DNR does not usually allow organ donation.

Less care for DNR patients

Reductions in other care are not supposed to result from a DNAPR decision being in place. Some patients choose DNR because they prefer less care: Half of Oregon patients with DNR orders who filled out a POLST wanted only comfort care, and 7% wanted full care. The rest wanted various limits on care, so blanket assumptions are not reliable. There are many doctors "misinterpreting DNR preferences and thus not providing other appropriate therapeutic interventions."

Patients with DNR are less likely to get medically appropriate care for a wide range of issues such as blood transfusions, cardiac catheterizations, cardiac bypass, operations for surgical complication, blood cultures, central line placement, antibiotics and diagnostic tests. " oviders intentionally apply DNR orders broadly because they either assume that patients with DNR orders would also prefer to abstain from other life-sustaining treatments or believe that other treatments would not be medically beneficial." 60% of surgeons do not offer operations with over 1% mortality to patients with DNRs. The failure to offer appropriate care to patients with DNR led to the development of emergency care and treatment plans (ECTPs), such as the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT), which aim to record recommendations concerning DNR alongside recommendations for other treatments in an emergency situation. ECTPs have prompted doctors to contextualise CPR within a broader consideration of treatment options, however ECTPs are most frequently completed for patients at risk of sudden deterioration and the focus tends to be on DNR.

Patients with DNR therefore die sooner, even from causes unrelated to CPR. A study grouped 26,300 very sick hospital patients in 2006-10 from the sickest to the healthiest, using a detailed scale from 0 to 44. They compared survival for patients at the same level, with and without DNR orders. In the healthiest group, 69% of those without DNR survived to leave the hospital, while only 7% of equally healthy patients with DNR survived. In the next-healthiest group, 53% of those without DNR survived, and 6% of those with DNR. Among the sickest patients, 6% of those without DNR survived, and none with DNR.

Two Dartmouth doctors note that "In the 1990s...'resuscitation' increasingly began to appear in the medical literature to describe strategies to treat people with reversible conditions, such as IV fluids for shock from bleeding or infection... the meaning of DNR became ever more confusing to health-care providers." Other researchers confirm this pattern, using "resuscitative efforts" to cover a range of care, from treatment of allergic reaction to surgery for a broken hip. Hospital doctors do not agree which treatments to withhold from DNR patients, and document decisions in the chart only half the time. A survey with several scenarios found doctors "agreed or strongly agreed to initiate fewer interventions when a DNR order was present.

After successful CPR, hospitals often discuss putting the patient on DNR, to avoid another resuscitation. Guidelines generally call for a 72-hour wait to see what the prognosis is, but within 12 hours US hospitals put up to 58% of survivors on DNR, and at the median hospital 23% received DNR orders at this early stage, much earlier than the guideline. The hospitals putting fewest patients on DNR had more successful survival rates, which the researchers suggest shows their better care in general. When CPR happened outside the hospital, hospitals put up to 80% of survivors on DNR within 24 hours, with an average of 32.5%. The patients who received DNR orders had less treatment, and almost all died in the hospital. The researchers say families need to expect death if they agree to DNR in the hospital.

Controlled Organ Donation After Circulatory Death (DCD)

In 2017, Critical Care Medicine (Ethics) and the American Society of Anesthesiologists (ASA) Committees on Transplant Anesthesia issued a statement regarding organ donation after circulatory death (DCD). The purpose of the statement is to provide an educational tool for institutions choosing to use DCD. In 2015, nearly 9% of organ transplantations in the United States resulted from DCD, indicating it is a widely-held practice. According to the President's Commission on Death Determination, there are two sets of criteria used to define circulatory death: irreversible absence of circulation and respiration, and irreversible absence of whole brain function. Only one criteria needs to be met for the determination of death before organ donation and both have legal standing, according to the 1980 Uniform Determination of Death Act (UDDA); a determination of death must be according to accepted medical standards. All states within the United States adhere to the original or modified UDDA. The dead donor role states that a patient should not be killed for or by the donation of their organs and that organs can only be procured from dead people (lungs, kidneys, and lobes of a liver may be donated by living donors in certain highly regulated situations). The definition of irreversibility centers around an obligatory period of observation to determine that respiration and circulation have ceased and will not resume spontaneously. Clinical examination alone may be sufficient to determine irreversibility, but the urgent time constraints of CDC may require more definitive proof of cessation with confirmatory tests, such as intra-arterial monitoring or Doppler studies. In accordance with the Institute of Medicine, the obligatory period for DCD is longer than 2 minutes but no more than 5 minutes of absent circulatory function before pronouncing the patient dead, which is supported by a lack of literature indicating that spontaneous resuscitation occurs after two minutes of arrest and that ischemic damage to perfusable organs occurs within 5 minutes.

Most patients considered for DCD will have been in the intensive care unit (ICU) and are dependent on ventilatory and circulatory support. Potential DCD donors are still completing the dying process but have not yet been declared dead, so quality end-of-life care should remain the absolute top priority and must not be compromised by the DCD process. The decision to allow death to occur by withdrawing life-sustaining therapies needs to have been made in accordance to the wishes of the patient and/or their legal agent; this must happen prior to any discussions about DCD, which should ideally occur between the patient's primary care giver and the patient's agent after rapport has been established.

Patients' values

The philosophical factors and preferences mentioned by patients and doctors are treated in the medical literature as strong guidelines for care, including DNR or CPR. "Complex medical aspects of a patient with a critical illness must be integrated with considerations of the patient's values and preferences" and "the preeminent place of patient values in determining the benefit or burden imposed by medical interventions." Patients' most common goals include talking, touch, prayer, helping others, addressing fears, laughing. Being mentally aware was as important to patients as avoiding pain, and doctors underestimated its importance and overestimated the importance of pain. Dying at home was less important to most patients. Three quarters of patients prefer longer survival over better health.

Advance directive, living will, POLST, medical jewellery, tattoos

Advance directives and living wills are documents written by individuals themselves, so as to state their wishes for care, if they are no longer able to speak for themselves. In contrast, it is a physician or hospital staff member who writes a DNR "physician's order," based upon the wishes previously expressed by the individual in their advance directive or living will. Similarly, at a time when the individual is unable to express their wishes, but has previously used an advance directive to appoint an agent, then a physician can write such a DNR "physician's order" at the request of that individual's agent. These various situations are clearly enumerated in the "sample" DNR order presented on this page.

It should be stressed that, in the United States, an advance directive or living will is not sufficient to ensure a patient is treated under the DNR protocol, even if it is their wish, as neither an advance directive nor a living will legally binds doctors. They can be legally binding in appointing a medical representative, but not in treatment decisions.

Physician Orders for Life-Sustaining Treatment (POLST) documents are the usual place where a DNR is recorded outside hospitals. A disability rights group criticizes the process, saying doctors are trained to offer very limited scenarios with no alternative treatments, and steer patients toward DNR. They also criticize that DNR orders are absolute, without variations for context. The Mayo Clinic found in 2013 that "Most patients with DNR/DNI o not intubateorders want CPR and/or intubation in hypothetical clinical scenarios," so the patients had not had enough explanation of the DNR/DNI or did not understand the explanation.

In the UK, emergency care and treatment plans (e.g. ReSPECT) are clinical recommendations written by healthcare professionals after discussion with patients or their relatives about their priorities of care. Research has found that the involvement of patients or their family in forming ECTP recommendations is variable. In some situations (where there are limited treatment options available, or where the patient is likely to deteriorate quickly) healthcare professionals will not explore the patient's preferences, but will instead ensure that patients or their relatives understand what treatment will or will not be offered.

Medical jewellery

Medical bracelets, medallions, and wallet cards from approved providers allow for identification of DNR patients outside in home or non-hospital settings. Each state has its own DNR policies, procedures, and accompanying paperwork for emergency medical service personnel to comply with such forms of DNR.

DNR tattoos

There is a growing trend of using DNR tattoos, commonly placed on the chest, to replace other forms of DNR, but these often cause confusion and ethical dilemmas among healthcare providers. Laws vary from state to state regarding what constitutes a valid DNR and currently do not include tattoos. End of life (EOL) care preferences are dynamic and depend on factors such as health status, age, prognosis, healthcare access, and medical advancements. DNR orders can be rescinded while tattoos are far more difficult to remove. At least one person decided to get a DNR tattoo based on a dare while under the influence of alcohol.

Ethics and violations

DNR orders in certain situations have been subject to ethical debate. In many institutions it is customary for a patient going to surgery to have their DNR automatically rescinded. Though the rationale for this may be valid, as outcomes from CPR in the operating room are substantially better than general survival outcomes after CPR, the impact on patient autonomy has been debated. It is suggested that facilities engage patients or their decision makers in a 'reconsideration of DNR orders' instead of automatically making a forced decision.

When a patient or family and doctors do not agree on a DNR status, it is common to ask the hospital ethics committee for help, but authors have pointed out that many members have little or no ethics training, some have little medical training, and they do have conflicts of interest by having the same employer and budget as the doctors.

In the United States there is accumulating evidence of racial differences in rates of DNR adoption. A 2014 study of end stage cancer patients found that non-Latino white patients were significantly more likely to have a DNR order (45%) than black (25%) and Latino (20%) patients. The correlation between preferences against life-prolonging care and the increased likelihood of advance care planning is consistent across ethnic groups.

There are also ethical concerns around how patients reach the decision to agree to a DNR order. One study found that patients wanted ''intubation'' in several scenarios, even when they had a Do Not Intubate (DNI) order, which raises a question whether patients with DNR orders may want CPR in some scenarios too.Capone's paper, and the original by Jesus et al. say the patients were asked about CPR, but the questionnaire shows they were only asked whether they wanted intubation in various scenarios. This is an example of doctors using the term resuscitation to cover other treatments than CPR. It is possible that providers are having a "leading conversation" with patients or mistakenly leaving crucial information out when discussing DNR.

One study reported that while 88% of young doctor trainees at two hospitals in California in 2013 believed they themselves would ask for a DNR order if they were terminally ill, they are flexible enough to give high intensity care to patients who have not chosen DNR.

There is also the ethical issue of discontinuation of an implantable cardioverter defibrillator (ICD) in DNR patients in cases of medical futility. A large survey of Electrophysiology practitioners, the heart specialists who implant pacemakers and ICDs, noted that the practitioners felt that deactivating an ICD was not ethically distinct from withholding CPR thus consistent with DNR. Most felt that deactivating a pacemaker was a separate issue and could not be broadly ethically endorsed. Pacemakers were felt to be unique devices, or ethically taking a role of "keeping a patient alive" like dialysis.

A self-report study from 1999 conducted in Germany and Sweden found that the frequency of resuscitations performed against patients' wishes (per DNR status) was as high as 32.5% among German doctors polled.

Violations and suspensions

Medical professionals can be subjected to ramifications if they are aware of a DNR. Each state has established laws and rules that medical providers must follow. For example, in some states within the US, DNRs only apply within a hospital, and can be disregarded in other settings. In these states, EMTs can therefore administer CPR until reaching the hospital where such laws exist.

If a medical professional knows of a DNR and continues with resuscitation efforts, then they can be sued by the family of the patient. This happens often, with a recent jury awarding $400,000 to the family of a patient for "Wrongful Prolongation of Life" in June 2021. Physicians and their attorneys have argued in some cases that when in doubt, they often err on the side of life-saving measures because they can be potentially be reversed later by disconnecting the ventilator. This was the case in 2013 when Beatrice Weisman was wrongfully resuscitated, leading to the family filing a lawsuit.

Bystanders who are not healthcare professionals working in a professional setting are protected under the Good Samaritan Law

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