What does DNR mean in medical terms?

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In the medical field, the abbreviation DNR stands for Do Not Resuscitate. In practice, this means that health care providers should not perform cardiopulmonary resuscitation (CPR) on patients designated DNR in the event that they stop breathing or the heart stops beating.

In short:

  • DNR means that the patient is not to be resuscitated in the event that the heart stops breathing or the heart stops beating.
  • Resuscitation typically refers to cardiopulmonary resuscitation (CPR) which can include mechanical chest compressions, giving electrical impulses to get the heart beating, artificial ventilation, and administration of certain drugs.
  • A DNR order is deemed appropriate with a DNR order is when CPR will not restart the heart or breathing, there is no benefit to the patient or the benefits are outweighed by the burdens.
  • Only doctors can issue a DNR order, but only after talking about it with the patient (if possible), the proxy, or the patient’s family.
  • A DNR order does not mean that all medical treatment is stopped.
  • A DNR order is not final. Patients can change their minds at any time by reaching out to the medical personnel.

What is resuscitation?

When a person stops breathing or the heart stops beating for a longer period of time (6 minutes and more), it is incompatible with life and will result in death. Therefore, in such an event it is common to initiate cardiopulmonary resuscitation. 

This treatment is aimed at keeping the blood circulating and oxygenated. This can be achieved by means of mechanical chest compressions, giving electrical impulses to get the heart beating, artificial ventilation, and administration of certain drugs.

Why would someone want a DNR?

In most countries, people have the right to decide what happens to them in case of an emergency. In practice, anyone can decide that they do not want to be resuscitated in the event that their heart stops beating or they stop breathing. That being said, a DNR order has to be claimed.

In practice, it’s most common for people who are approaching the end of their life to decide that they do not want to be resuscitated in an event where CPR is necessary to sustain life. Most often, this includes people that have reached a substantial age and/or those with an incurable illness that will not improve.

The main reason for this is that the chance of surviving an event that necessitates CPR decreases with old age and having one or several major health conditions. That being said, age and illness alone is not necessarily a reason for a DNR order. Ultimately, the circumstances in which is deemed appropriate with a DNR order is when CPR will not restart the heart or breathing, there is no benefit to the patient or the benefits are outweighed by the burdens.

In several countries, doctors are able to order a DNR even if the family disagrees with the decision. In such an event it is important to engage in constructive dialog in order to solve the conflict.  

How is a DNR order established?

The practices surrounding how a DNR order is issued vary between countries. According to MedlinePlus, which is a service of the U.S National Library of Medicine, only doctors can issue a DNR order, but only after talking about it with the patient (if possible), the proxy, or the patient’s family. 

The decision not to be resuscitated is hard for the patient as well as their family. Ideally, the decision should be taken by the patient, after discussing it with both their family and their treating doctor(s). When the decision is made, the doctor must follow the patient’s wishes, or hand over the task to another doctor who will.

A DNR order is communicated both orally and written. When admitted to a hospital the DNR order can be recorded in your medical chart (written or electronic) and communicated orally between staff. In an outpatient setting, it can be communicated orally or written in a will or other documents. Alternatives include DNR cards that are kept in a wallet or worn bracelets. DNR orders can also be recorded in a hospice or nursing home care plan.

The practices surrounding how a DNR order is established and recorded varies between countries. In the united states and most of western Europe, the issue is most commonly discussed with both the patient and the family and recorded both orally and written (journal, electronic).

When the patient is unable to make the decision

If the patient has an established DNR order, it can not be overruled by anyone. However, In the event that injury or illness prevents the patient to state his/her wishes about CPR, the decision can fall someone else.

If the patient has named someone to speak on their behalf (family member or health care worker), that person has the right to agree on a DNR order on the patient’s behalf. If this is not the case, a family member or friend may also agree to a DNR order, but only when the patient is unable to make medical decisions for themselves.  

Do a DNR order mean that treatment is stopped?

A DNR order does not mean that all medical treatment is stopped. A DNR order typically only puts limitations on which interventions are to be initiated in order to resume breathing or to get the heart beating. Most commonly this includes chest compressions or giving electric shocks to keep/restore circulation (heartbeat) and ant form of assisted ventilation to sustain breathing.

It is possible to retain certain resuscitation treatments while excluding others. For example, patients might not want chest compressions to be initiated, but give electric shocks to the heart when applicable in the event of a cardiac arrest. This is something that should be discussed with the treating doctor.

Is a DNR final? 

A DNR order is not final. Patients can change their minds at any time by reaching out to the medical personnel. Also, a patient’s condition can change, in which case, a DNR is not warranter. 

In such an event it is important to inform all caregivers and family members about the decision change. Also, all documents stating the DNR order should be destroyed and to avoid any confusion.

References

  1. Laura J. Martin, MD, David Zieve, MD, and the A.D.A.M. Editorial team. Do-not-resuscitate order. https://medlineplus.gov/ency/patientinstructions/000473.htm
  2. Charles N Pozner, MD et al. Advanced cardiac life support (ACLS) in adults. Sep 18, 2019. https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults
  3. James Downar, MDCM, MHSc, FRCP, Tracy Luk, MD, FRCP(C), Robert W. Sibbald, MSc, Tatiana Santini, et al. Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients. J Gen Intern Med. 2011 Jun; 26(6): 582–587. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3101966/
  4. Charles Sabatino, JD. Do-Not-Resuscitate (DNR) Orders. msdmanuals, September 2018. https://www.msdmanuals.com/home/fundamentals/legal-and-ethical-issues/do-not-resuscitate-dnr-orders
  5. Cleveland clinic Ethics resources and services. “Do Not Resuscitate” (DNR) Orders and Comfort Care. 2010 Cleveland clinical health system. https://my.clevelandclinic.org/ccf/media/files/Bioethics/DNR%20Handout%204_28.pdf
  6. Vanpee D, Swine CScale of levels of care versus DNR ordersJournal of Medical Ethics 2004;30:351-352. https://jme.bmj.com/content/30/4/351