Do not resuscitate

Alternative terms

Other terms and abbreviations for this order are used in different countries. DNR (Do Not Resuscitate) is a common abbreviation in the United States, Canada and the United Kingdom. It may be clarified in some regions with the addition of DNI (Do Not Intubate), although in some hospitals DNR alone will imply no intubation. Clinically, the vast majority of people requiring resuscitation will require intubation, making a DNI alone problematic.

Some areas of the United States and the United Kingdom include the letter A, as in DNAR, to clarify "Do Not Attempt Resuscitation." This alteration is so that it is not presumed by the patient or family that an attempt at resuscitation will be successful. Since the term DNR implies the omission of action, and therefore "giving up", some have advocated for these orders to be retermed Allow Natural Death. New Zealand and Australia, and some hospitals in the UK, use the term NFR or Not For Resuscitation. Typically these abbreviations are not punctuated, e.g., DNR rather than D.N.R.

Another synonymous term is "not to be resuscitated" (NTBR).

Until recently in the UK it was common to write "Not for 222" or conversationally, "Not for twos." This was implicitly a hospital DNR order, where 222 (or similar) is the hospital telephone number for the emergency resuscitation or crash team.

Advance directive and living will

Advance directives and living wills are documents written by individuals themselves, so as to state their wishes for care, if they are no longer able to speak for themselves. In contrast, it is a physician or hospital staff member who writes a DNR "physician's order," based upon the wishes previously expressed by the individual in his or her advance directive or living will. Similarly, at a time when the individual is unable to express his wishes, but has previously used an advance directive to appoint an agent, then a physician can write such a DNR "physician's order" at the request of that individual's agent. These various situations are clearly enumerated in the "sample" DNR order presented on this page.

It should be stressed that, in the United States, an advance directive or living will is not sufficient to ensure a patient is treated under the DNR protocol, even if it is his wish, as neither an advance directive nor a living will is a legally binding document.

Ethics

DNR orders in certain situations have been subject to ethical debate. In many institutions it is customary for a patient going to surgery to have their DNR automatically rescinded. Though the rationale for this may be valid, as outcomes from CPR in the operating room are substantially better than general survival outcomes after CPR, the impact on patient autonomy has been debated. It is suggested that facilities engage patients or their decision makers in a 'reconsideration of DNR orders 'instead of automatically making a forced decision.

There is accumulating evidence of a racial bias in DNR adoption. A 2014 study of end stage cancer patients found that non-Latino white patients were significantly more likely to have a DNR order (45%) than black (25%) and Latino (20%) patients. The correlation between preferences against life-prolonging care and the increased likelihood of advance care planning is consistent across ethnic groups.

Ethical dilemmas occur when a patient with a DNR attempts suicide and the necessary treatment involves ventilation or CPR. In these cases it has been argued that the principle of beneficence takes precedence over patient autonomy and the DNR can be revoked by the physician. Another dilemma occurs when a medical error happens to a patient with a DNR. If the error is reversible only with CPR or ventilation there is no consensus if resuscitation should take place or not.

There are also ethical concerns around how patients reach the decision to make themselves a DNR. One study found that when questioned in more detail, many patients who were DNR actually would have wanted the excluded interventions depending on the scenario. Most would prefer life saving intubation in the scenario of angioedema which typically resolves in days. One fifth of the DNR patients would want resuscitation for cardiac arrest but to have care withdrawn after a week. It is possible that providers are having a "leading conversation" with patients or mistakenly leaving crucial information out when discussing DNR. One study reported that physicians repeatedly give high intensity care to patients while deciding they themselves would be DNR under similar circumstances.

There is also the ethical issue of discontinuation of an ICD implantable cardioverter defibrillator in DNR patients in cases of medical futility. A large survey of Electrophysiology practitioners, the heart specialists who implant pacemakers and ICD's noted that the practitioners felt that deactivating an ICD was not ethically distinct from withholding CPR thus consistent with DNR. Most felt that deactivating a pacemaker was a separate issue and could not be broadly ethically endorsed. Pacemakers were felt to be unique devices, or ethically taking a role of "keeping a patient alive" like dialysis.

Usage by country

DNR documents are widespread in some countries and unavailable in others. In countries where a DNR is unavailable the decision to end resuscitation is made solely by physicians.

Middle East

DNRs are not recognized by Jordan. Physicians attempt to resuscitate all patients regardless of individual or familial wishes. The UAE have laws forcing healthcare staff to resuscitate a patient even if the patient has a DNR or does not wish to live. There are penalties for breaching the laws. In Saudi Arabia patients cannot legally sign a DNR, but DNR accepted by order of primary physician in case of terminally ill patients. In Israel, it is possible to sign a DNR form as long as the patient is dying and aware of their actions.

England and Wales

In England and Wales, CPR is presumed in the event of a cardiac arrest unless a do not resuscitate order is in place. If they have capacity as defined under the Mental Capacity Act 2005 the patient may decline resuscitation, however any discussion is not in reference to consent to resuscitation and instead should be an explanation. Patients may also specify their wishes and/or devolve their decision-making to a proxy using an advance directive, which are commonly referred to as 'Living Wills'. Patients and relatives cannot demand treatment (including CPR) which the doctor believes is futile and in this situation, it is their doctor's duty to act in their 'best interest', whether that means continuing or discontinuing treatment, using their clinical judgment. If they lack capacity relatives will often be asked for their opinion out of respect.

Scotland

In Scotland, the terminology used is "Do Not Attempt Cardiopulmonary Resuscitation" or "DNACPR". There is a single policy used across all of NHS Scotland. The legal standing is similar to that in England and Wales, in that CPR is viewed as a treatment and, although there is a general presumption that CPR will be performed in the case of cardiac arrest, this is not the case if it is viewed by the treating clinician to be futile. Patients and families cannot demand CPR to be performed if it is felt to be futile (as with any medical treatment) and a DNACPR can be issued despite disagreement, although it is good practice to involve all parties in the discussion.

United States

In the United States the documentation is especially complicated in that each state accepts different forms, and advance directives and living wills are not accepted by EMS as legally valid forms. If a patient has a living will that specifies the patient requests to be DNR but does not have a properly filled out state sponsored form that is co-signed by a physician, EMS will attempt resuscitation.

The DNR decision by patients was first litigated in 1976 in In re Quinlan. The New Jersey Supreme Court upheld the right of Karen Ann Quinlan's parents to order her removal from artificial ventilation. In 1991 Congress passed into law the Patient Self-Determination Act that mandated hospitals honor an individual's decision in their healthcare. Forty-nine states currently permit the next of kin to make medical decisions of incapacitated relatives, the exception being Missouri. Missouri has a Living Will Statute that requires two witnesses to any signed advance directive that results in a DNR/DNI code status in the hospital.

In the United States, cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) will not be performed if a valid written "DNR" order is present. Many states do not recognize living wills or health care proxies in the prehospital setting and prehospital personnel in those areas may be required to initiate resuscitation measures unless a specific state sponsored form is properly filled out and cosigned by a physician.

Canada

Do not resuscitate orders are similar to those used in the United States. In 1995, the Canadian Medical Association, Canadian Hospital Association, Canadian Nursing Association, and Catholic Health Association of Canada worked with Canadian Bar Association clarify and create a Joint Statement on Resuscitative Interventions guideline for use to determine when and how DNR orders are assigned. DNR orders must be discussed by doctors with the patient or patient agents or patient's significant others. Unilateral DNR by medical professionals can only be used if the patient is in a vegetative state.