Do-Not-Resuscitate (DNR) Orders
A do-not-resuscitate (DNR) order placed in a person’s medical record by a doctor informs the medical staff that cardiopulmonary resuscitation (CPR) should not be attempted. Because CPR is not attempted, other resuscitative measures that follow it (such as electric shocks to the heart and artificial respirations by insertion of a breathing tube) will also be avoided. This order has been useful in preventing unnecessary and unwanted invasive treatment at the end of life. The success rate of CPR near the end of life is extremely low. (See also Overview of Legal and Ethical Issues in Health Care.)
Doctors should discuss with seriously ill patients the possibility of cardiopulmonary arrest (when the heart stops and breathing ceases) in light of their immediate medical condition, describe CPR procedures and likely outcomes, and ask patients about treatment preferences. If a person is incapable of making a decision about CPR, an authorized surrogate may make the decision.
A DNR order does not mean "do not treat." Rather, it means only that CPR will not be attempted. Other treatments (for example, antibiotic therapy, transfusions, dialysis, or use of a ventilator) that may prolong life can still be provided. Depending on the person's condition, these other treatments are usually more likely to be successful than CPR. Treatment that keeps the person free of pain and comfortable (called palliative care) should always be given.
Most states also provide for special DNR orders that are effective outside of hospitals, wherever the person may be in the community. These are called out-of-hospital DNR orders, Comfort Care orders, No CPR orders, or other terms. Generally, they require the signature of the doctor and patient (or patient’s surrogate), and they provide the patient with a visually distinct quick identification form, bracelet, or necklace that emergency medical services personnel can identify. These orders are especially important for terminally ill people living in the community who want only comfort care and no resuscitation if their heart or breathing stops. Living wills and health care powers of attorney are not generally effective in emergency situations. Many states are now incorporating DNR status into a portable medical order called Physician Orders for Life Sustaining Treatment.
A growing number of state and local programs address a range of emergency life-sustaining treatments in addition to cardiopulmonary resuscitation (CPR) for people with advanced illness. These programs are most commonly called Physician Orders for Life-Sustaining Treatment or POLST but can have other names, including Medical Orders for Life-Sustaining Treatment (MOLST), Physician Orders for Scope of Treatment (POST), Medical Orders for Scope of Treatment (MOST), and Transportable Physician Orders for Patient Preferences (TPOPP).
POLST and similar programs involve a physician-initiated discussion and shared decision-making process with people with advanced or end-stage illness. It results in a portable set of medical orders, consistent with the person’s goals of care, addressing the person’s wishes in regards to the use of CPR, artificial nutrition and hydration, hospitalization, ventilation, intensive care, and other interventions that potentially could be used in a medical crisis. POLST is applicable across all care settings. In a medical crisis, emergency medical technicians and other health care practitioners should first follow POLST. If immediate action is not essential, POLST should be reviewed with the person whenever the person's condition changes significantly, the person's venue of care changes, or the person chooses to change his or her wishes. For people lacking decision-making capacity, their authorized surrogates can act on their behalf. POLST differs from advance directives in that it applies only to people with advanced illness, it provides a treatment plan in the form of medical orders for emergency decisions, and it is focused on the person’s current condition, not a future hypothetical condition.
POLST and similar programs do not exist in every state or community, but their development is spreading rapidly.