What Is a DNR (Do Not Resuscitate) Order?

A do-not-resuscitate (DNR) order is a legally recognized order signed by a physician at a patient’s request. A DNR means the patient not want to be resuscitated if they suddenly go into cardiac arrest or stop breathing.

People who are terminally ill often regard a DNR as a graceful way to leave the world on their terms. The details of a DNR are usually discussed at the time of admission to a hospital, nursing facility, or hospice program.

This article explains the meaning of DNR. It details what resuscitation means and the rules governing DNR orders. It also takes a look at how to make a DNR order work for you and the ethical considerations of a DNR.

What DNR Means

DNR means do not resuscitate. Without a DNR, a healthcare provider will take action to revive a person who is unconscious or whose heart or breathing has stopped. A DNR means that the person does not want any life-saving measures.

Resuscitation means to revive or bring back to life. Common resuscitation methods include:

• Chest compressions: When a person’s heart stops beating, the heart cannot pump blood to the rest of the body, including the brain and lungs. Pushing down on the chest repeatedly can help keep blood flowing throughout the body until heart function is restored.
• Intubation: When breathing becomes difficult or impossible due to an illness or injury, a patient may be intubated. This involves inserting an endotracheal tube through the mouth and into the airway. The tube is then connected to a ventilator, which pushes air into the lungs.
• Cardioversion: Cardioversion is used to correct abnormal heart rhythms, including arrhythmias and atrial fibrillation (also known as AFib). This may be done using a set of paddles to deliver an electrical shock to the heart or via medication.
• IV medications: Medications that are sometimes used in the case of cardiac arrest include epinephrine, amiodarone, vasopressin, and atropine sulfate. These are “crash cart medications,” so named because they can be found on the wheeled cart that medical professionals use during an emergency resuscitation.

For a patient in cardiac or respiratory arrest, a DNR means that none of these tactics will be used.

Resuscitation Side Effects

Successful resuscitation can cause significant physical injuries. For example, chest compressions can cause broken ribs, punctured lungs, and possibly a damaged heart.

Those who are resuscitated may also suffer brain damage. This can occur due to lack of blood flow to the brain followed by abnormal cell activity when blood flow to the brain is restored. Generally, the risk increases the longer the duration of CPR.

Resuscitation Survival Rates

Survival statistics for resuscitation vary widely, partly due to the fact that there are many variables involved, including the age and health status of the patient and whether CPR was performed in a hospital, where emergency support is available.

A 2021 review looked at research published from 2008 onward that focused on the outcome of CPR in patients aged 70 and older following in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA). Survival rates were 28.5% and 11.1%, respectively.

Meanwhile, a Danish study found that 30-day survival rates among nursing home residents who received CPR after OHCA was only 7.7%.

Types of DNR Orders

A DNR order is sometimes referred to by other names that mean the same, such as:

• Do not attempt resuscitation
• Do not attempt cardiopulmonary resuscitation

Healthcare providers may also use the terms no code or allow natural death, which can have different meanings.

No Code

In a hospital, an order to withhold resuscitation is sometimes called a “no code” to distinguish it from a “full code” or “code blue,” both of which mean every effort should be made to resuscitate a patient.

Allow Natural Death

While a DNR order simply states that no attempts should be made to restart breathing or restart the heart if it stops, an allow natural death (AND) order ensures that only comfort measures are taken.

This would include withholding or discontinuing resuscitation, artificial feedings, fluids, and other measures that would prolong a natural death. These orders are typically used in hospice settings or elsewhere for terminally ill patients.

DNR Order Rules

DNR orders are applied according to state laws, which vary from state to state. This can cause confusion.

Some states use standardized forms for DNR orders. If the order is not written on that specific form, it cannot be honored. Other states are less regimented and honor any type of clear DNR order.

In most states, DNR orders are required to follow some of the same general rules in order to be valid. DNR orders must:

• Be written by a doctor rather than verbalized: Exceptions to this may be made. For example, an emergency medical service physician may direct EMS personnel to withhold resuscitation via the radio. A registered nurse may also take an order from an admitting doctor over the phone in some cases. Generally, there are safeguards for these exceptions to make sure the order is validated later.
• Be signed by a doctor: In those cases where orders were taken by a nurse over the phone, states usually set a deadline for the doctor to physically verify and sign the order.
• Include the patient’s name and the date of the order: Depending on the state, orders may expire after a certain amount of time, or there may be a deadline for the physician to follow up. Even if a DNR order doesn’t expire, a particularly old order may prompt a caregiver to revisit the decision.

Some states allow emergency responders to follow DNR orders written to other care providers. For instance, in New York State, paramedics and emergency medical technicians (EMTs) are usually allowed to follow DNR orders written for the staff of a nursing home.

Each state is different, and municipalities may differ within each state.

Making a DNR Order Work for You

If you opt for a DNR order, here’s what you can do to ensure your wishes are respected:

• Keep the physical order on hand and display it wherever paramedics might find you. Make a point to tell them about the order when they arrive. It’s a good idea to have more than one copy available and displayed, as well as a copy to bring with you to the hospital.
• If you are traveling, ask your traveling partners to keep a copy of your DNR order on them at all times.
• Consider wearing a piece of medical jewelry to alert others of your intentions. MedicAlert Foundation provides jewelry designed specifically for patients with DNR orders. The foundation keeps a copy of the order on file and can fax it anywhere in the world.
  

Ethical Complications of DNR Orders

The inconsistent application of DNR orders means some patients may get less than optimal care once providers are aware of the presence of a DNR order.

It’s important to remember that a DNR order is not an order to withhold all treatment. It is only an order not to resuscitate.

The Patient Self Determination Act (PDSA) requires that the wishes of an individual and any existing advance directives be honored in the United States. However, providers do occasionally disregard a DNR; this may be due to due to a lack of communication, for example.

It’s also possible that an existing DNR is honored, but providers fail to confirm with a patient or their representative.

Even the mere mention of a DNR can spawn a wide range of reactions, many of them emotionally charged. Discuss the options with your doctor and your family when everyone is calm and rational—and hopefully sooner rather than later.

Summary

A do-not-resuscitate order instructs healthcare providers to refrain from cardiopulmonary resuscitation (CPR) if a patient’s breathing stops or if the patient’s heart stops beating. CPR can also pose a dilemma, but one worth considering, especially in the context of your health (or the health of a loved one). That's because it requires the heart to be compressed hard and deep enough to pump the blood out of the heart. As such, it can lead to broken ribs, punctured lungs, and possibly a damaged heart. Those who are resuscitated may also suffer brain damage.

These actions may be too much for someone in frail health. If you wish to explore a DNR order, it’s important to know that the orders vary from state to state. Be sure to investigate the rules in your area before proceeding.