In Ohio there are several legally recognized ways for you to give doctors and other health care providers instructions about the extent and limitations of the medical treatment you wish to receive, before you actually need the care. You may have heard about advance directives such as living wills and health care powers of attorney. Ohio law also recognizes another tool, called a “DNR order,” which helps you and your doctor effectively plan your health care for the end of life. Unlike a living will or health care power of attorney, a DNR order is a medical order that a physician or other authorized person must write.
What does DNR mean?
DNR stands for “Do Not Resuscitate.” A person who does not wish to have cardiopulmonary resuscitation (CPR) performed, for example, may make this wish known through a DNR order. A DNR order also addresses the various methods used to revive people whose hearts have stopped functioning or who have stopped breathing. Examples of these treatments include chest compressions, electric heart shock, artificial breathing tubes and special drugs.
Under its DNR Comfort Care Protocol, the Ohio Department of Health has established two standardized DNR orders. When completed by a doctor (or certified nurse practitioner or clinical nurse specialist, as appropriate), these standardized DNR orders allow patients to choose the extent of the treatment they wish to receive at the end of life. A patient with a DNR Comfort Care-Arrest Order will receive all the appropriate medical treatment, including resuscitation, until the patient has a cardiac arrest (heart has stopped beating) or pulmonary arrest (breathing has stopped), at which point comfort care will be provided. By requesting a DNR Comfort Care Order (DNR-CC), a patient chooses other measures such as drugs to correct abnormal heart rhythms. With this order, comfort care or other requested treatment is provided at a point before the heart or breathing stops. Comfort care (also called symptom management or palliative care) involves keeping the patient comfortable with pain medication and providing palliative (supportive medical) care. A DNR-CC does not mean “do not treat.” Your doctor can explain the differences in DNR orders.
At the time of this printing, Ohio has two trigger points for the DNR protocol (the DNR Comfort Care and DNR Comfort Care-Arrest), but DNR protocol changes are being considered. Consult your health care professional for details.
Does everyone want CPR?
Although in some cases it does save lives, CPR (cardiopulmonary resuscitation) frequently is not successful or does not benefit those who receive it, especially elderly people or those with serious medical conditions. Even if revived, the person can be left with painful injuries, or in a debilitated state, or with brain damage resulting from oxygen deprivation. Resuscitation can involve such things as drugs, forcefully pressing on the chest, giving electric shocks to restart the heart or placing a tube down the nose or throat to provide artificial breathing. People with terminal illnesses or other serious health conditions may prefer not to be resuscitated when the end nears. For more information about the pros and cons of CPR and whether it is right for you, talk with your doctor, your family and, perhaps, your religious leader.
How do I make my wishes about CPR known? How do I get a DNR order?
If you do want to receive CPR when it is medically appropriate, you do not have to do anything. Emergency squads and other health care providers must provide CPR if you stop breathing or your heart stops beating. If you do not want CPR, you always have the right to refuse it (or any other medical treatment), but you may not be able to state your wishes when an emergency happens. Therefore, if you do not want CPR, you should speak with your doctor about your wishes, and whether it would be appropriate for you to have a DNR order (a medical order saying that CPR should not be given).
The doctor will explain the different ways the order can be written. Your doctor is encouraged to use the standard Ohio DNR identification form. This form, which is easily recognized by paramedics and other health care workers, remains in effect in any Ohio health care center and can be accessed through the Ohio Department of Health’s website at www.odh.ohio.gov
Why did Ohio adopt a law about DNR?
Ohio’s 1991 living will law focused on patients in hospitals and nursing homes and, over the years, uncertainty grew about the circumstances under which an emergency health care worker could act on a DNR order and honor a person’s wish not to have CPR. The purpose of the 1998 DNR law is to help people communicate their wishes about resuscitation to medical personnel outside a hospital or nursing home setting. It allows emergency medical workers to honor patients’ physician-written DNR orders even if the patient is at home rather than in the hospital when the heart or breathing stops. The 1998 DNR law also protects emergency squads and other health care providers from liability if they follow their patients’ DNR orders outside a hospital or nursing home setting.
How will the emergency squad or others know I have a DNR order?
It is wise to provide your doctor and your local hospital with a copy of your advance directives and DNR identification form before an emergency arises. If you are a patient in a hospital or nursing home, the DNR order should be in your medical chart. You or your family also should notify the medical staff that you have such an order any time you are admitted to a facility or are transferred from one facility to another. If you are receiving care at home, you should tell your family and caregivers where to find your DNR order and post it in an easy-to-find place, such as your refrigerator door. You also may want to ask your doctor about getting DNR identification such as a wallet card or bracelet that tells medical personnel you have a DNR order.
Can anyone override my wishes about CPR?
You have the right to make your own decisions about your health care. If you cannot express your wishes, other people such as your legal guardian, a person you named in a health care power of attorney or a family member can speak for you. You should make sure these people know your desires about CPR. If your doctor writes a DNR order at your request, no one can override it.
What if I change my mind after my doctor writes a DNR order?
You always have the right to change your mind and request CPR. If you do change your mind, talk with your doctor right away about revoking your DNR order. You also should tell your family and caregivers about your decision, mark “cancelled” on the actual DNR order, and destroy any DNR wallet cards or other identification items you may have. If you have a DNR order, but change your mind about the level of care you would want regarding CPR and medical interventions that may prolong life, you will need a new order. Generally, a new DNR will revoke and older DNR.
What is the difference between a living will and a DNR order?
Both living wills and DNR orders deal with end-of-life decisions, but they are different. You may complete a living will document yourself even when you are healthy. Your living will document specifies in advance the kind of medical treatment you would want if and when you have a terminal illness or are in a permanently unconscious state and are no longer able to state your own wishes.
Unlike a living will, you do not write a DNR order for yourself. Instead, you make your wishes known to your doctor, who writes a DNR order if and when your condition warrants it. The DNR order addresses your current state of health and the kind of medical treatment you and your physician decide is appropriate under current circumstances.
A living will may not protect you from receiving CPR or other medical interventions that may prolong life. It only takes effect if you are in a certifiably terminal or permanently unconscious state, and emergency squad personnel cannot determine if you meet these conditions. A DNR order provides better protection, if you are sure you do not want CPR or other interventions.
How does a person use a living will to obtain a DNR order?
Ohio has a standard, widely available living will declaration form. This standard form specifically directs your doctor to write a DNR order for you if two doctors have agreed that you are either terminally ill or permanently unconscious. Your attorney and your doctor can help answer questions about the living will form, including the DNR issue.
How does a health care power of attorney differ from a living will? From a DNR order?
Another kind of advance directive available under Ohio law is the health care power of attorney. Whenever you are unable to make health care decisions for yourself, this document names another person to do so (usually a spouse, child, or other relative, and preferably someone who can understand your health status and make potentially difficult decisions on your behalf, if necessary). These decisions could range from deciding whether to see a doctor to deciding whether to have surgery or discontinue treatment.
Unlike a health care power of attorney, a living will expresses your wishes directly to the health care provider and applies only if you are terminally ill or permanently unconscious.
Although a health care power of attorney is not a DNR order, it ordinarily permits the person you appoint to agree to a DNR order for you, if you are unable to express your wishes at the time.
Can I use a general power of attorney to address my health care wishes?
No. You may have given your general power of attorney to someone to manage your financial affairs while you were on vacation or in the hospital. This general power of attorney usually does not address health care issues and ends if you become disabled.
If you want a general power of attorney to continue, even if you become disabled, the document must state that it is a durable, or continuing, power of attorney. A health care power of attorney is a durable power; it continues even after you become disabled and appoints someone to carry out your health care wishes. Health care providers will more readily recognize your power of attorney if it is in a separate document expressly addressing health care matters.
How are DNR orders, living wills and health care powers of attorney used?
A living will might be used to direct a physician to write a DNR order. For example:
Jane decides she does not want to receive CPR. She obtains a living will form and completes it properly. Later, Jane becomes debilitated and needs home health care, but has not discussed resuscitation with her doctor and a specific DNR order has not been written. One day, the visiting nurse finds that Jane is not breathing. At this point, the nurse begins CPR, because a DNR order has not been written. If Jane is resuscitated and transferred to a hospital, her doctors may write a DNR order, but only if they decide she is terminally ill or permanently unconscious. Jane’s living will can serve as evidence that she does not want to be resuscitated in such a circumstance. Her doctor may write a DNR order so that, if Jane's heart stops beating again, she will not be resuscitated.
A health care power of attorney might be used to authorize a DNR order. For example:
Bill decides that, under some circumstances, he would not want to receive CPR and informs his family of this decision. He completes a health care power of attorney form, appointing his wife to make health care decisions for him if he is unable to do so. Later, Bill is seriously injured in an accident and is moved to a hospital while he is unconscious. Bill’s wife shows the doctors the health care power of attorney document and explains that Bill would not want CPR if his heart or lungs should stop functioning. The doctors write a DNR “CC-Arrest” order, indicating on Bill’s medical chart that he is not to be resuscitated if he dies, but that he should receive aggressive medical treatment before that time. Bill receives treatment including medicine, a breathing tube and other resuscitative measures, until his heart stops. At that point, the health care workers do not try to resuscitate him.
A DNR order alone might be used, as in the following example:
John is chronically ill and decides he does not want to receive CPR, although he wants limited medical treatment. He talks with his doctor, who writes a “DNR-CC” order on the DNR Identification Form provided by the Ohio Department of Health, signs it, and gives it to John. Later, John needs home health care. He tells his family about his DNR order and gives them a copy. One day, his daughter finds that John is having trouble breathing. She calls 9-1-1, and shows the DNR order to the medic who arrives. The medic transports John to the hospital, where he is treated with antibiotics for pneumonia and is sent back home. A week later, John stops breathing. His daughter calls 9-1-1, and again shows the DNR order to the medic. This time, since John has stopped breathing, the squad does not resuscitate him, although John receives comfort care.
Where can I get further information? Can I draw up my own documents?
You cannot draw up your own DNR order. Instead, you will need to speak with your doctor, who can complete the appropriate forms for the order, and can tell you how to obtain a wallet card, bracelet or other DNR identification.
You may draw up your own living will and health care power of attorney documents, but it is a good idea to consult with an attorney about how these documents fit into your overall estate plan. The Ohio State Bar Association, the Ohio State Medical Association, the Midwest Care Alliance, the Ohio Osteopathic Association and the Ohio Hospital Association jointly revised a standard living will declaration form and a standard health care power of attorney form. You do not have to use the standard forms, but your documents must meet certain requirements under Ohio law. You may want your lawyer to prepare documents that are specifically tailored to your situation. You can get the standard forms from doctors, lawyers, hospitals, nursing homes and others. You also may mail a request for the forms along with $4 to LeadingAge Ohio (formerly Midwest Care Alliance), 2233 North Bank Drive, Columbus, OH 43220, or visit that organization’s website at www.midwestcarealliance.org
© March 2014 Ohio State Bar Association
LawFacts Pamphlet Series
Ohio State Bar Association
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