What Is a Do-Not-Resuscitate (DNR) Order?

Understanding the DNR form

A do-not-resuscitate order represents a critical component of advance care planning that allows you to maintain control over your medical treatment during life-threatening emergencies. When you have a DNR order in place, medical professionals are legally bound to respect your wishes and refrain from attempting to restart your heart or breathing through simple efforts or invasive procedures. 

Without a DNR order, emergency medical services personnel and hospital staff are trained to immediately begin resuscitation efforts, which is often referred to as "coding" a patient. The directive applies specifically to cardiopulmonary resuscitation techniques, which may include chest compressions, electric shock to the person’s heart, artificial breathing devices, and even intubation. These procedures, while potentially life-saving, may not align with your personal values or medical situation.

A do-not-resuscitate order can also provide peace of mind for family members. The form clearly communicates your wishes and removes the need for guessing or conflicting perspectives on the part of your family.

Legal and ethical considerations for DNR orders

DNR orders exist within a complex framework of medical law, patient rights, and ethical principles that vary across different states. 

State-specific DNR requirements

State laws regarding DNR orders can differ in their requirements, procedures, provisions, and even terminology. Some states may call it a "do not attempt resuscitation" (DNAR) form or an "allow natural death" (AND) form. Most states require that DNR orders be signed by a physician who has examined you and determined that resuscitation would be medically inappropriate or contrary to your expressed wishes.

Some states may require in-hospital vs. out-of-hospital DNR orders. For instance, Texas has a specific Out-of-Hospital Do-Not-Resuscitate program for individuals who may not find themselves in a hospital setting. New York also requires a different form for out-of-hospital settings, called the Non-Hospital DNR.

• In-hospital DNR orders are typically easier to implement because your medical team has access to your complete medical records and can verify your wishes through established protocols. Hospital staff are trained to recognize DNR orders in patient charts and to communicate this information during emergencies within the facility.
• Out-of-hospital DNR orders present unique challenges because emergency medical personnel must be able to quickly identify and verify your wishes during crisis situations. Many states have developed special identification systems for out-of-hospital DNR orders. For example, Ohio legally recognizes DNR form identification cards, forms, necklaces, or bracelets approved by the state's Department of Health.

If you move to a different state, you'll need to verify that your existing DNR order remains valid under your new state's laws, as recognition of out-of-state orders is not universal.

Ethical perspectives on do-not-resuscitate decisions

The ethical dimensions of DNR orders involve balancing respect for patient autonomy with medical professionals' duty to preserve life. According to research published in the American Journal of Medicine, healthcare providers must navigate complex ethical considerations when discussing DNR orders with patients and families. These conversations require careful attention to informed consent, ensuring that patients understand both the implications of having a DNR order and the potential consequences of resuscitation attempts.

Religious and cultural perspectives play significant roles in DNR decisions, with some faith traditions emphasizing the sanctity of life while others focus on accepting natural death. Healthcare providers are trained to respect these diverse viewpoints while ensuring that patients receive accurate medical information to make informed choices. The ethical principle of beneficence—acting in the patient's best interest—requires considering quality of life, likelihood of successful resuscitation, and the patient's own values and preferences.

How to create and implement a DNR order

Creating a valid DNR order involves several important steps that ensure your wishes are properly documented and legally enforceable. 

Step 1: Consult with your healthcare provider

Your physician will likely be required by state law to sign your DNR order, so their involvement is typically essential for creating a legally valid document.

Begin by scheduling a comprehensive discussion with your primary care physician or specialist about your desire for a DNR order. Your doctor will review your medical history, current health status and any medical conditions, and prognosis to help you understand the implications of your decision. This conversation should cover what resuscitation involves, the likelihood of successful outcomes in your specific situation, and how a DNR order fits into your overall care plan. 

Step 2: Complete required documentation

Obtain the appropriate DNR form for your state, which may be available through your doctor's office, hospital, or state health department website. Most states have specific standardized DNR forms, or DNR orders are included within broader advance directive documents. 

Fill out all required information completely and accurately, ensuring that your personal identification information matches your legal documents. Pay careful attention to any witness or notarization requirements, as these vary by state, and failure to comply can invalidate your DNR order.

Step 3: Ensure proper medical record documentation

Work with your healthcare provider to ensure that your DNR order is properly documented in your medical records and communicated to all relevant members of your care team. This documentation should include the date the order was created, the medical or personal reasons supporting the decision, and any specific instructions about your care preferences. If you are hospitalized, your DNR status should be clearly noted in your chart and communicated during shift changes and care transitions. 

Keep original copies of your DNR order in multiple accessible locations, including with your primary care physician, in your home medical file, and with trusted family members. Consider storing copies in your wallet or purse, particularly if you have a higher risk of medical emergencies. If you use multiple healthcare providers or specialists, ensure that each one has a copy of your DNR order and understands how it fits into your overall care plan. 

Step 4: Communicate with family and caregivers

Inform your family members, close friends, and any caregivers about your DNR order, and explain your reasoning for this decision. Provide them with copies of your DNR documentation and provide instructions about where to find the original documents when needed. Consider discussing your wishes during family meetings or including this information in your advance directive to prevent confusion or conflicts during medical emergencies.

Step 5: Arrange for emergency recognition

If you want your DNR order to apply in emergency situations outside of healthcare facilities, take steps to ensure that first responders can quickly identify your wishes. This may involve obtaining a state-approved DNR identification bracelet or necklace and keeping a copy of your out-of-home DNR order in a visible location in your home.

How to update or revoke a DNR order

DNR orders can be modified or completely revoked at any time while you remain mentally competent to make medical decisions. To update your do-not-resuscitate order, follow the same process you used to create the original document, including consultation with your physician and completion of any required forms. Changes to your DNR status should be communicated immediately to all healthcare providers, family members, and caregivers who were aware of your previous wishes.

If you decide to revoke a DNR order, you can simply inform your healthcare providers verbally or in writing that you no longer want the order in effect. However, it's advisable to complete formal revocation documentation to ensure there is no confusion about your current wishes. Destroy or clearly mark as "REVOKED" any copies of your previous DNR order, as well as any identification bracelets or necklaces, to prevent accidental implementation of outdated instructions. Update your medical records, advance directives, and any emergency identification systems to reflect your current preferences.

DNR form vs. other advance directives

A do-not-resuscitate form differs from other types of advance directives and medical orders. Here is a brief overview of the differences between DNR, living will, POLST, and DNI.