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What You Should Know about Do Not Resuscitate (DNR) Orders


Q: What does DNR mean?
A:
DNR stands for “Do Not Resuscitate.” A person who does not wish to have cardiopulmonary resuscitation (CPR) performed may make this wish known through a doctor’s order called a DNR order. A DNR order 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 (patient has stopped breathing), 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 would be provided at a point even before the heart or breathing stops. Comfort care involves keeping the patient comfortable with pain medication and providing palliative care.  A DNR-CC order does not mean “do not treat.”  Your doctor can explain the differences in DNR orders.

Ohio currently has two trigger points for the DNR protocol (the DNR Comfort Care and DNR Comfort Care-Arrest), but changes regarding DNR protocol are being considered. Consult your health care professional for details.

Q: Does everyone want CPR?
A:
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. 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.

Q: How do I make my wishes about CPR known? How do I get a DNR order?
A:
If you do want to receive CPR when it is medically appropriate, you don’t have to do anything. Emergency squads and other health care providers must give CPR whenever a person is without heartbeat or respirations. If you do not want CPR, you always have the right to refuse it (or any other medical treatment), but there is a good chance you won’t be able to state your wishes when an emergency happens. Therefore, if you do not want CPR, you should talk 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 is easily recognized by paramedics and other health care workers, and can be accessed through the Ohio Department of Health’s Web site at http://www.odh.state.oh.us/.

Q: Why did Ohio adopt a law about DNR?
A:
Because Ohio’s 1991 Living Will Law focused on patients in hospitals and nursing homes, there was uncertainty 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 they are 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.

Q: How will the emergency squad or anyone else know I have a DNR order?
A:
It would be wise to give your doctor and your local hospital a copy of your advance directives and DNR Identification Form before an emergency arise.  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 put it in an easy-to-find place, such as your refrigerator door. You also may want to talk with your doctor about getting DNR identification such as a wallet card or bracelet that tells medical personnel you have a DNR order.

Q: Can anyone else override my wishes about CPR?
A:
You have the right to make your own decisions about your health care. If you are unable to 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, your family cannot override it.

Q: What if I change my mind after my doctor writes a DNR order?
A:
You always have the right to change your mind and request CPR. If you do change your mind, you should 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.

Q: How does a person use a living will to obtain a DNR order?
A:
Ohio has a standard Living Will Declaration form that is widely available. 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.

12/1/2010

Law You Can Use is a weekly consumer legal information column provided by the Ohio State Bar Association.

Articles appearing in this column are intended to provide broad, general information about the law. Before applying this information to a specific legal problem, readers are urged to seek advice from an attorney.

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