The Utility of DNR Orders

By By Brady Scheiner



Do-not-resuscitate orders, also known as DNR orders, are typically intended to legally indicate that someone does not want to receive cardiopulmonary resuscitation (CPR) in the case of cardiac arrest. Sometimes, they are used to prevent other life-saving interventions, but this is not as common. In order to properly give a DNR order, the physician must obtain the informed consent of the patient (or their guardian). For more information on the process of informed consent, click here!


There are two general types of DNR orders: DNR Comfort Care (DNR-CC) orders and DNR Comfort Care-Arrest (DNR-CCA) orders, with DNR-CCA orders being the most common type. This order permits the use of life-saving interventions, such as chemotherapy, curative surgery, or medication, up until one’s breathing or heart stops; after this point, only interventions relating to one’s comfort are permitted (Ethics Committee). Basically, CPR will not be provided, but physicians are still expected to provide the patient with comfort care to the best of their abilities. In contrast, DNR-CC orders require that only comfort care be provided even before the patient’s breathing or heart stops (Ethics Committee). This type of order is typically used in the case of a short life expectancy or terminal illness where curative treatment does not prove to be beneficial. Another option at some hospitals is often referred to as DNR-Specified, which is a custom order crafted by a patient in consultation with their physician (Ethics Committee). This allows for a more individualized DNR order, but is unavailable at many hospitals and non-transferable between institutions. When DNR orders are discussed broadly, they are likely referring to DNR-CCA orders, as they are the least restrictive and most frequent.


Like a lot of legislation in the medical field, DNR orders are not without complication. In recent years, researchers have found that the presence of a DNR order in a patient’s charts can unintentionally decrease the use of non-CPR medical interventions (Mccaughey). Ultimately, this lower level of care can prove fatal; in fact, it was found that, following a hip surgery, patients with DNR orders had over double the mortality rate of patients without one (Mccaughey). Another frequent issue with DNR orders is that physicians may not adequately discuss the complications with DNR orders, which would constitute a lack of informed consent. Additionally, a DNR order may be overridden against a patient’s wishes; a survey of physicians showed that 69% would be very likely to disregard a DNR order and perform CPR anyways if their treatment caused a cardiac arrest (Tan). This is thought to be due to lawsuit concerns, guilt, or a lack of consideration of this possibility (Tan). On the other end of this issue, DNR orders are sometimes placed against a patient’s will, which is known as a unilateral DNR (Courtwright, et al.). Generally, this decision is made by an ethics committee or physician when they deem further treatment to be futile (Courtwright, et al.). This is especially concerning because in some cases, the patients were found to have potentially treatable conditions (Courtwright, et al.). There is lots of ongoing debate and contention surrounding this issue, even among doctors, as roughly half are opposed to this practice (Putman).


To find out the specifics of DNR orders in your state, search “DNR order laws” followed by your state! For example, a search for “DNR order laws in (insert state here)” should bring up all the information you need!



Citations

Courtwright, A., et al. “Unilateral Do-Not-Attempt Resuscitation Orders at

the Massachusetts General Hospital.” Medical Futility Blog, 11 May

2014,

medicalfutility.blogspot.com/2014/05/unilateral-do-not-attempt-resusci

tation.html?utm_source=twitterfeed&utm_medium=twitter.

Ethics Committee. “DNR Orders and Comfort Care.” Ethics Resources and

Services, Cleveland Clinic,

my.clevelandclinic.org/ccf/media/Files/Bioethics/DNR%20Handout%204_28.pdf?la=en#:~:text=DNR%20Comfort%20Care%2DArrest%3A%20DNR,person's%20heart%20or%20breathing%20stops.

Mccaughey, Betsy. “Do Not Sign A DNR Before You Read This.” Investor's

Business Daily, 28 Mar. 2018,

www.investors.com/politics/columnists/do-not-resuscitate-dnr-orders- dangerous-for-patients/.

Putman, Micheal S. “Ethics of Unilateral DNR Orders: Physicians Are

Evenly Divided.” Relias Media - Continuing Medical Education

Publishing, 1 Feb. 2018, www.reliasmedia.com/articles/142102-ethics-of-unilateral-dnr-orders-physicians-are-evenly-divided.

Tan, S. Y. “Consent and DNR Orders.” The Hospitalist, 14 Feb. 2018,

www.the-hospitalist.org/hospitalist/article/158675/business-medicine/

consent-and-dnr-orders.


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