Do not resuscitate
A do-not-resuscitate order, also known as no code or allow natural death, is a legal order, written or oral depending on country, indicating that a person does not want to receive cardiopulmonary resuscitation if that person's heart stops beating. Sometimes it also prevents other 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 wishes and values.
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 ; and philosophical factors.Audio recordings of 19 discussions about DNR status between doctors and patients in 2 US hospitals 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."
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, 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.
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.
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 after 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, 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 DNR, but they do. 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. "roviders 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.
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.
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 jewelry, tattoos
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 his or her advance directive or living will. Similarly, at a time when the individual is unable to express his 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 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 orders 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.
Medical jewelry
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 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 if the individual changes their mind. Uncommonly, some individuals have decided to get their DNR tattoo based on a dare while under the influence.Ethics
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.
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 than black and Latino patients. The correlation between preferences against life-prolonging care and the increased likelihood of advance care planning is consistent across ethnic groups.
Ethical dilemmas occur when a patient with a DNR attempts suicide and the necessary treatment involves ventilation or CPR. In these cases it has been argued that the principle of beneficence takes precedence over patient autonomy and the DNR can be revoked by the physician. Another dilemma occurs when a medical error happens to a patient with a DNR. If the error is reversible only with CPR or ventilation there is no consensus if resuscitation should take place or not.
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 order, which raises a question whether patients with DNR orders may want CPR in some scenarios too. 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 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.
Terminology
DNR and Do Not Resuscitate are common terms in the United States, Canada, New Zealand and the United Kingdom. This may be expanded in some regions with the addition of DNI. In some hospitals DNR alone will imply no intubation, though 98% of intubations are unrelated to cardiac arrest; most intubations are for pneumonia or surgery. Clinically, the vast majority of people requiring resuscitation will require intubation, making a DNI alone problematic. Hospitals sometimes use the expression no code, which refers to the jargon term code, short for Code Blue, an alert to a hospital's resuscitation team.Some areas of the United States and the United Kingdom include the letter A, as in DNAR, to clarify "Do Not Attempt Resuscitation". This alteration is so that it is not presumed by the patient or family that an attempt at resuscitation will be successful.
As noted above in Less care for DNR patients, the word "resuscitation" has grown to include many treatments other than CPR, so DNR has become ambiguous, and authors recommend "No CPR" instead.
Since the term DNR implies the omission of action, and therefore "giving up", a few authors have advocated for these orders to be retermed Allow Natural Death.
Others say AND is ambiguous whether it would allow morphine, antibiotics, hydration or other treatments as part of a natural death.
New Zealand and Australia, and some hospitals in the UK, use the term NFR or Not For Resuscitation. Typically these abbreviations are not punctuated, e.g., DNR rather than D.N.R.
Resuscitation orders, or lack thereof, can also be referred to in the United States as a part of Physician Orders for Life-Sustaining Treatment, Medical Orders for Life-Sustaining Treatment, Physician's Orders on Scope of Treatment or Transportable Physician Orders for Patient Preferences orders, typically created with input from next of kin when the patient or client is not able to communicate their wishes.
Another synonymous term is "not to be resuscitated".
Until recently in the UK it was common to write "Not for 222" or conversationally, "Not for twos". This was implicitly a hospital DNR order, where 222 is the hospital telephone number for the emergency resuscitation or crash team.
Usage by country
DNR documents are widespread in some countries and unavailable in others. In countries where a DNR is unavailable the decision to end resuscitation is made solely by physicians.A 2016 paper reports a survey of doctors in numerous countries, asking "how often do you discuss decisions about resuscitation with patients and/or their family?" and "How do you communicate these decisions to other doctors in your institution?" Some countries had multiple respondents, who did not always act the same, as shown below. There was also a question "Does national guidance exist for making resuscitation decisions in your country?" but the concept of "guidance" had no consistent definition, For example, in the US, four respondents said Yes, and two said No.
| Country | Discuss with Patient or Family | Tell Other Doctors the Decision |
| Argentina | Rarely | Oral |
| Australia | Most, Half | Oral+Notes+Pre-printed, Notes |
| Austria | Half | Notes |
| Barbados | Half | Oral+Notes |
| Belgium | Half, Rarely | Notes+Electronic |
| Brazil | Most | Oral+Notes |
| Brunei | Rarely | Oral+Notes |
| Canada | Always, Most | Oral+Notes, Oral+Notes+Electronic, Notes+Pre-printed |
| Colombia | Half | Oral |
| Cuba | Always | Oral |
| Denmark | Most | Electronic |
| France | Most | Pre-printed, |
| Germany | Always | Oral+Notes+Electronic |
| Hong Kong | Always, Half | Notes+Pre-printed, Oral+Notes+Pre-printed |
| Hungary | Rarely | Oral |
| Iceland | Rarely | Notes+Electronic |
| India | Always | Notes, Oral, Oral+Notes |
| Ireland | Most, Rarely | Notes |
| Israel | Most, Half | Oral+Notes Notes |
| Japan | Most, Half | Oral, Notes, |
| Lebanon | Most | Oral+Notes+Electronic |
| Malaysia | Rarely | Notes |
| Malta | Most | Notes |
| New Zealand | Always | Pre-printed |
| Netherlands | Half | Electronic |
| Norway | Always, Rarely | Oral, Notes+Electronic |
| Pakistan | Always | Notes+Electronic |
| Poland | Always, Most | Oral+Notes, Notes+Pre-printed |
| Puerto Rico | Always | Pre-printed |
| Saudi Arabia | Always, Most | Pre-printed, Notes+Electronic, Oral |
| Singapore | Always, Most, Half | Pre-printed, Oral+Notes+Pre-printed, Oral+Notes+Electronic, Oral+Pre-printed |
| South Africa | Rarely | Oral+Notes |
| South Korea | Always | Pre-printed |
| Spain | Always, Most | Pre-printed, Oral+Notes+Electronic, Oral+Notes+Pre-printed |
| Sri Lanka | Most | Notes |
| Sweden | Most | Oral+Notes+Pre-printed+Electronic |
| Switzerland | Most, Half | Oral+Notes+Pre-printed, Oral+Notes+Other |
| Taiwan | Half, Rarely | Notes+Pre-printed+Other, Oral |
| UAE | Half | Oral+Notes |
| Uganda | Always | Notes, |
| USA | Always, Most | Notes, Electronic, Oral+Electronic, Oral+Notes+Electronic, Oral+Notes+Pre-printed+Electronic |
Middle East
DNRs are not recognized by Jordan. Physicians attempt to resuscitate all patients regardless of individual or familial wishes. The UAE have laws forcing healthcare staff to resuscitate a patient even if the patient has a DNR or does not wish to live. There are penalties for breaching the laws. In Saudi Arabia patients cannot legally sign a DNR, but a DNR can be accepted by order of the primary physician in case of terminally ill patients. In Israel, it is possible to sign a DNR form as long as the patient is dying and aware of their actions.United Kingdom
England and Wales
In England and Wales, CPR is presumed in the event of a cardiac arrest unless a do not resuscitate order is in place. If they have capacity as defined under the Mental Capacity Act 2005 the patient may decline resuscitation, however any discussion is not in reference to consent to resuscitation and instead should be an explanation. Patients may also specify their wishes and/or devolve their decision-making to a proxy using an advance directive, which are commonly referred to as 'Living Wills'. Patients and relatives cannot demand treatment which the doctor believes is futile and in this situation, it is their doctor's duty to act in their 'best interest', whether that means continuing or discontinuing treatment, using their clinical judgment. If the patient lacks capacity, relatives will often be asked for their opinion out of respect.Scotland
In Scotland, the terminology used is "Do Not Attempt Cardiopulmonary Resuscitation" or "DNACPR". There is a single policy used across all of NHS Scotland. The legal standing is similar to that in England and Wales, in that CPR is viewed as a treatment and, although there is a general presumption that CPR will be performed in the case of cardiac arrest, this is not the case if it is viewed by the treating clinician to be futile. Patients and families cannot demand CPR to be performed if it is felt to be futile and a DNACPR can be issued despite disagreement, although it is good practice to involve all parties in the discussion.United States
In the United States the documentation is especially complicated in that each state accepts different forms, and advance directives and living wills may not be accepted by EMS as legally valid forms. If a patient has a living will that specifies the patient requests DNR but does not have a properly filled out state-sponsored form that is co-signed by a physician, EMS may attempt resuscitation.The DNR decision by patients was first litigated in 1976 in In re Quinlan. The New Jersey Supreme Court upheld the right of Karen Ann Quinlan's parents to order her removal from artificial ventilation. In 1991 Congress passed into law the Patient Self-Determination Act that mandated hospitals honor an individual's decision in their healthcare. Forty-nine states currently permit the next of kin to make medical decisions of incapacitated relatives, the exception being Missouri. Missouri has a Living Will Statute that requires two witnesses to any signed advance directive that results in a DNR/DNI code status in the hospital.
In the United States, cardiopulmonary resuscitation and advanced cardiac life support will not be performed if a valid written DNR order is present. Many states do not recognize living wills or health care proxies in the prehospital setting and prehospital personnel in those areas may be required to initiate resuscitation measures unless a specific state-sponsored form is properly filled out and cosigned by a physician.
Canada
Do not resuscitate orders are similar to those used in the United States. In 1995, the Canadian Medical Association, Canadian Hospital Association, Canadian Nursing Association, and Catholic Health Association of Canada worked with the Canadian Bar Association to clarify and create a Joint Statement on Resuscitative Interventions guideline for use to determine when and how DNR orders are assigned. DNR orders must be discussed by doctors with the patient or patient agents or patient's significant others. Unilateral DNR by medical professionals can only be used if the patient is in a vegetative state.Australia
In Australia, Do Not Resuscitate orders are covered by legislation on a state-by-state basis.In Victoria, a Refusal of Medical Treatment certificate is a legal means to refuse medical treatments of current medical conditions. It does not apply to palliative care. An Advanced Care Directive legally defines the medical treatments that a person may choose to receive in various defined circumstances. It can be used to refuse resuscitation, so as avoid needless suffering.
In NSW, a Resuscitation Plan is a medically authorised order to use or withhold resuscitation measures, and which documents other aspects of treatment relevant at end of life. Such plans are only valid for patients of a doctor who is a NSW Health staff member. The plan allows for the refusal of any and all life-sustaining treatments, the advance refusal for a time of future incapacity, and the decision to move to purely palliative care.
Italy
DNRs are not recognized by Italy. Physicians must attempt to resuscitate all patients regardless of individual or familial wishes. Italian laws force healthcare staff to resuscitate a patient even if the patient has a DNR or does not wish to live. There are jail penalties for healthcare staff breaching this law, e.g. "omicidio del consenziente". Therefore, in Italy a signed DNR has no legal value.Taiwan
In Taiwan, patients sign their own DNR orders, and are required to do so to receive hospice care. However, one study looking at insights into Chinese perspectives on DNR showed that the majority of DNR orders in Taiwan were signed by surrogates. Typically doctors discuss the issue of DNR with the patients family rather than the patient themselves. In Taiwan, there are two separate types of DNR forms: DNR-P which the patient themselves sign and DNR-S in which a designated surrogate can sign. Typically, the time period between signing the DNR and death is very short, showing that signing a DNR in Taiwan is typically delayed. Two witnesses must also be present in order for a DNR to be signed.DNR orders have been legal in Taiwan since May 2000 and were enacted by the Hospice and Palliative Regulation. Also included in the Hospice and Palliative Regulation is the requirement to inform a patient of their terminal condition, however, the requirement is not explicitly defined leading to interpretation of exact truth telling.
Japan
In Japan, DNR orders are known as Do Not Attempt Resuscitation. Currently, there are no laws or guidelines in place regarding DNAR orders but they are still routinely used. A request to withdraw from life support can be completed by the patient or a surrogate. In addition, it is common for Japanese doctors and nurses to be involved in the decision making process for the DNAR form.France
In 2005, France implemented its "Patients' Rights and End of Life Care" act. This act allows the withholding/withdrawal of life support treatment and as well as the intensified usage of certain medications that can quicken the action of death. This act also specifies the requirements of the act.The "Patients' Rights and End of Life Care" Act includes three main measures. First, it prohibits the continuation of futile medical treatments. Secondly, it empowers the right to palliative care that may also include the intensification of the doses of certain medications that can result in the shortening the patient's life span. Lastly, it strengthens the principle of patient autonomy. If the patient is unable to make a decision, the discussion, thus, goes to a trusted third party.