A “Do Not Resuscitate” (DNR) order is a specific type of health care directive.
If a person’s heart stops beating or the person stops breathing, the DNR instructs health care providers not to perform cardiopulmonary resuscitation to revive them. In other words, the DNR voices a person’s preference to die a natural death.
A DNR order can sound scary or daunting, but it can protect a person who is no longer able to speak for themselves from undergoing invasive interventions which they have deemed undesirable.
The DNR order is empowering, especially for people with serious or terminal illnesses.
It offers control over end-of-life choices and care, ensuring that personal values and beliefs are respected.
Health care directive vs. DNR
A health care directive (also known as a “living will” or “advance directive”) is a legal document that outlines a person’s heath care wishes, including the use of CPR and other interventions such as
• mechanical ventilation for breathing support
• intravenous fluids
• medications such as antibiotics
• artificial nutrition with tubes into the intestines
Although a health care directive documents a person’s wishes about end-of-life care, it is not a medical order and may not be followed in a medical emergency unless the person can communicate their wishes at the time.
In contrast, the POLST (Portable Orders for Life-Sustaining Treatment) is a medical order signed by a person’s health care provider that summarizes the types of life-sustaining treatment the person wants, including the use of CPR.
The orders are called “portable” because they are intended to go with the patient from one health care setting to another, including the home.
The POLST form can be downloaded from the Washington State Medical Association at https://wsma.org/wsma/resources/advance-care-planning/polst.aspx.
In the home setting, the selection of “Do Not Attempt Resuscitation” on the POLST form permits paramedics and other medical responders called to a scene where a patient has lost heartbeat and/or breath to allow for a natural death.
Otherwise, medical responders are legally obligated to initiate CPR and attempt revival.
If CPR is started for a patient with a POLST indicating DNR, CPR should be stopped in the absence of a pulse.
In a hospital or nursing home situation, a POLST form or a patient’s oral request not to have CPR must be confirmed by a written DNR order in the medical chart that is signed by the patient’s health care provider.
Once the DNR order is signed, the patient is identified with a wristband or room sign with their DNR status.
While a DNR order prevents a patient from undergoing invasive interventions which they have deemed undesirable, it does not mean that a person should not receive other medical treatments. A DNR order still allows for other aspects of medical care including:
• surgical interventions
• aggressive medication regimens
• chemotherapy and radiation therapy
• clinical trial investigation therapies
• pain relief
A DNR order is part of a care plan deigned to help people live as long as they can, with as much quality as possible, but not have a death that lasts any longer than what nature has in store for them.
A DNR order takes effect only when the person is unable to communicate their wishes on their own.
Furthermore, it can be revoked at any time for any reason.
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Cardiopulmonary resuscitation (CPR) is an emergency treatment that is undertaken when someone’s breathing or heartbeat has stopped. It usually consists of forceful chest compressions sometimes combined with artificial ventilation such as mouth-to-mouth breathing.
CPR can be lifesaving, but its success depends on how quickly it is initiated and the health of the patient before the event that led to the initiation of CPR. For example, patients with advanced chronic conditions like cancer, heart failure, or dementia have lower survival rates following CPR than patients with acute illnesses such as a heart attack or heart arrhythmia.
Attempting CPR on a patient with a serious and life-limiting disease that has progressed to the point of no pulse or breathing is usually futile. Even if the person’s pulse and breathing are restored by CPR, the effort usually just prolongs their death.
After CPR most patients are admitted to an intensive care unit for a stay that involves pain from broken ribs, artificial ventilation requiring sedation, multiple tubes, and other invasive interventions which are unlikely to provide a meaningful quality of life. Patients’ families often regret seeing their loved ones go through weeks of misery only to die a few days or weeks after the CPR attempt.
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Thomas Kummet is a retired medical oncologist who worked at the Olympic Medical Cancer Center in Sequim for many years. Volunteer Hospice of Clallam County provides person-centered compassionate care to patients through their end-of-life journey, respite care and companionship, grief support, and educational and awareness-raising programs.
To learn more about Volunteer Hospice of Clallam County, go to https://volunteerhospice.org/, email office@vhocc.org or call 360-452-1511.
