n medicine, a "do not resuscitate" or "DNR" is a legal order written either

in the hospital or on a legal form to respect the wishes of a patient to not

undergoCPR or advanced cardiac life support if their heart were to stop or
they were to stop breathing. This request is usually made by the patient or
health carepower of attorney and allows the medical teams taking care of
them to respect their wishes. n the health care community "allow natural
death" or "AND" is a term that is quickly gaining favor as it focuses on what
is being done, not what is being avoided. Some critics the term "do not
resuscitate" sounds as if something important is being withheld, while
research shows that only about 5% of patients who require ACLS outside
the hospital and only 15% of patients who require ACLS while in the
hospital survive
[1]

[2]
. Patients who are elderly, are living in nursing homes,
have multiple medical problems, or who have advanced cancer are much
less likely to survive.
[3]

A DNR does not affect any treatment other than that which would
require intubation or CPR. Patients who are DNR can continue to get
chemotherapy, antibiotics, dialysis, or any other appropriate treatments.
DNR documents are widespread in some countries and unavailable in
others. n countries where a DNR is unavailable the decision to end
resuscitation is made solely by physicians. n 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. f a patient has a living will that states the patient wishes
to be DNR but does not have an appropriately filled out state sponsored
form that is co-signed by a physician, EMS will attempt resuscitation. This
is a little known fact to many patients and primary care physicians that can
cause patients to receive treatments they do not want, and this law is
currently being evaluated for a constitutional challenge.







Alternative names
Alternative namings and abbreviations for this order are used depending on
the geographic region. DNR (Do Not Resuscitate) is a common
abbreviation in the United States and the United Kingdom. t may be
clarified in some regions with the addition of DNI (Do Not ntubate),
although in some hospitals DNR alone will imply no intubation. Clinically,
the vast majority of people requiring resuscitation will require intubation,
making a DN 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/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.
[4]
New Zealand and Australia (and
some hospitals in the UK) use the term NFR or Not For Resuscitation.
Typically, these abbreviations are written without periods between the
letters, i.e.AND/DNR not A.N.D./D.N.R..
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.
[citation needed]

[edit]DNR vs advance directive and Iiving wiII
Advance directives and living wills are documents used for patients to write
down their wishes for care if he or she is no longer able to speak for himself
or herself. Based on what is written in this document, the patient can be
made a DNR by hospital staff. However, in the United States this document
alone is not sufficient to ensure a patient is DNR, even if it is their wish as
neither form is a legally binding document.

Like a dried-apple doll's, Carmela's 99-year-old wrinkled smile was sweet

but a little spooky. She had come to the hospital from home, with two
daughters in their 70s, her little old medical doctor of 30 years, Dr. Jones
(also in his 70s), most of her teeth and one badly broken hip. They're not
too impressed with high-functioning centegenarians in my hospital
anymore; we get quite a few these days. But Carmela stood out. She was a
little deaf and a slightly wacky but she had a twinkle about her. She was
just so cute and vivacious that you couldn't help liking her. And she loved to
talk only not in English. Her hearty Neapolitan dialect went up and down
like the heaving deck of a ship, straining my year of college talian. When
she realized could make her out, though, it sealed the deal we would,
of various necessities, be friends.
t took a few days, many medicines and quite a few units of packed red
cells to get her blood counts up to the point where she could have the hip
operation safely. This is a dicey business with the very old. The
transfusions put them into heart failure (the heart can't keep up with the
fluid overload, which backs up into the lungs), which has to be treated with
diuretics, which drop their pressure, which ruins their kidneys, which makes
the heart failure worse. Pneumonia, bed sores, blood clots and dementia
nip at them too, along with the paralyzing pain of the broken hip, almost
from the minute they fall. t's dangerous to let hip fractures go too long pre-
op and somewhat inhumane. Ask anyone who has had one; the
operation relieves a terrible pain. t is very gratifying as a surgeon to pin a
hip. But to whisk Carmela straight off to the operating room with just six
grams of hemoglobin and wet lungs, would have almost certainly killed her.
So we had to wait while her medical men did their thing. And her relatives
signed the DNR.
DNR means Do Not Resuscitate. t's a legal document that patients or
(more often) their loved ones sign in the presence of witnesses. t says that
if the patient gets into certain kinds of trouble, we're not supposed to use
"extraordinary means" to help them out. Typically it means if their heart
stops we can't code them and if they have trouble breathing we can't put in
the endotracheal tube to keep them breathing on a machine. mplicit, it
seems, in a DNR order is the idea that the patient's "quality of life" is so low
that it's not worth the pain, discomfort and indignity of coding and
ventilation. (Even the most pragmatic fans of DNR feel queasy about
adding "and the expense" here.) Also implicit is that the emergency
usually a heart or lung problem we're not treating because of the DNR
order will quickly prove fatal.
An unfixed hip fracture is usually fatal too. But even having asked for the
DNR, there was no question how Carmela's family felt about this they
wanted me to fix Mama's hip. So when she was ready, we got some more
blood and brought her down to the OR. They couldn't get a spinal into her
twisted, arthritic back so the anesthesiologists put her to sleep, put in the
tube, put her on the breathing machine. As we worked on the hip, her
ancient heart got balky. So they gave her the same drugs and used the
same electrical devices they might have used in a code. And it worked. We
sewed her up and taped on a bandage. Some pain meds and antibiotics, a
few more units of blood, and a few days later there she was in the chair by
her bed, all smiles and wrinkles again, red bandanna on her head, eating
everything on her tray, babbling on in talian about how Americans eat
garbage, making me late for the office. could already see the happy
ending. How great it would be to send her off to rehab now, close the case
and blast the DNR commies to hell.
Then she got sick. could hear the rattle in her chest the next morning. Her
color was off too. Three days later she was brightly jaundiced, yellow as a
banana, working hard to breathe. She lay on her side, so small, swollen
and miserable with belly pain. Rounds were faster with her because she
couldn't say more than a few words but far less happy. Boy did she look
old.
Little old Dr. Jones was upset too: "'m treating the pneumonia but the
daughters won't let her have an ERCP. What can do? Can you talk to the
daughters? even tried to explain it to Carmela. But don't think she can
understand."
ERCP (for endoscopic retrograde cholangiopancreatography) is a non-
surgical procedure to unplug the blocked ducts around the liver. These
ducts were probably backing up with infected bile, making Carmela sick.
was sure she didn't like being sick. But was not sure Carmela understood
she had been deemed incompetent to make the decision to have ERCP
herself. How could anyone even try to bring up the DNR topic with her?
caught up with the family the next night. They took me down to the other
end of the hall to talk.
"You let me put her to sleep, cut her open, bang a metal nail into her bone,
transfuse all that blood, and you won't let the G doctor slip a tube down her
throat with a little Valium?"
"She's been through so much," was pretty much all they had to say.
They wouldn't let her have it, so we used the antibiotic. And it worked. After
another week, her color was back to normal; all signs of infection were
gone. saw old Jones in the hall and gave him our doctorly congratulations.
Great save, Ken.
On rounds there she was again, sitting having breakfast, looking at the
Gideons at her bedside. had some time so we talked.
"Feeling better?"
"Yes the hip is good."
She bragged about the five steps she had taken around her room that day.
But sensed that the talk about the hip was just holding me off. Doctors are
allowed to ask questions so bored in. But my friend wouldn't discuss her
belly, her color, her appetite or anything else having to do with that last,
sick week. Carmela wasn't right a good mood, ostensibly, but there was
a hole in her. t bothered me, so joked. "Well, hope your daughters are
coming in with some better food than this tonight."
Her smile crashed and she looked away.
Oh, well, no big deal. She'd spent three weeks in the hospital; had five or
six major medical problems; she was an old, old lady. Lots of the usual
reasons for mental status changes, even emotional lability. The medicines,
the pain, the unfamiliar surroundings. Yet, almost certainly, another thing
had been broken, more painful, perhaps, than her hip.
That night got into bed, purposefully considering all the good things about
Carmela's case: her chest was clear, labs normal, hip stable. We were just
waiting for a rehab spot now. But the question gnawed. t's unfortunate answer
arrived before morning. t was 1:53 a.m. when the night nurse called.
"Sorry to wake you, but Dr. Jones just wanted me to let you know..."
"...No, they didn't because, you know, she was so old. And she was DNR and
all."
"This is a complete waste of time," said aloud, sitting up after trying for three
hours to get back to sleep. A waste of effort, of time, money and blood is how
many in my medical community would have described our dealings with Carmela
over those three weeks. Such pragmatic folk doubt would have had much
trouble getting back to sleep that night.
But was it the DNR that killed her? ndirectly, maybe. think it was realizing that
her daughters planned to withhold care that made her give up. When you're 99,
though, doesn't something have to get you? How many years of care can a 75-
year-old child give a mother? So many questions, and such huge, universal
ones, revolved around that wrinkled smile. At least one of them the ancient
question about a doctor's role in this situation came with an answer. An old
teacher of mine explained it this way: " will neither give a deadly drug nor will
make a suggestion to this effect."



On the medicine wards, you will come across patients who have a "Do-Not-
Resuscitate" order on their chart. You will also be in situations where you are asked to
discuss with a patient whether they want to or should have resuscitation Iollowing a
cardiac arrest or liIe-threatening arrhythmia. Like many other medical decisions,
deciding whether or not to resuscitate a patient who suIIers a cardiopulmonary arrest
involves a careIul consideration oI the potential likelihood Ior clinical beneIit with the
patient's preIerences Ior the intervention and its likely outcome. Decisions to Iorego
cardiac resuscitation are oIten diIIicult because oI real or perceived diIIerences in
these two considerations. (See also Do Not Resuscitate Orders during Anesthesia and
Urgent Procedures.)
When should CPR be administered?
Cardiopulmonary resuscitation (CPR) is a set oI speciIic medical procedures designed to
establish circulation and breathing in a patient who's suIIered an arrest oI both. CPR is a
supportive therapy, designed to maintain perIusion to vital organs while attempts are made to
restore spontaneous breathing and cardiac rhythm.
II your patient stops breathing or their heart stops beating in the hospital, the standard
oI care is to perIorm CPR in the absence oI a valid physician's order to withhold it.
Similarly, paramedics responding to an arrest in the Iield are required to administer
CPR. Since 1994 in Washington state, patients may wear a bracelet that allows a
responding paramedic to honor a physician's order to withhold CPR.
When can CPR be withheld?
Virtually all hospitals have policies which describe circumstances under which CPR can be
withheld. Two general situations arise which justiIy withholding CPR:
O when CPR is judged to be oI no medical beneIit (also known as "medical
Iutility"; see below), and
O when the patient with intact decision making capacity (or when lacking such
capacity, someone designated to make decisions Ior them) clearly indicates that
he / she does not want CPR, should the need arise.
When is CPR "futile"?
CPR is "Iutile" when it oIIers the patient no clinical beneIit. When CPR oIIers no
beneIit, you as a physician are ethically justiIied in withholding resuscitation. Clearly
it is important to deIine what it means to "be oI beneIit." The distinction between
merely providing measurable eIIects (e.g. normalizing the serum potassium) and
providing beneIits is helpIul in this deliberation.
When is CPR not of benefit?
One approach to deIining beneIit examines the probability oI an intervention leading
to a desirable outcome. CPR has been prospectively evaluated in a wide variety oI
clinical situations. Knowledge oI the probability oI success with CPR could be used to
determine its Iutility. For instance, CPR has been shown to be have a 0 probability
oI success in the Iollowing clinical circumstances:
O Septic shock
O Acute stroke
O etastatic cancer
O Severe pneumonia
In other clinical situations, survival Irom CPR is extremely limited:
O ypotension (2 survival)
O Renal Iailure (3)
O AIDS (2)
O omebound liIestyle (4)
O Age greater than 70 (4 survival to discharge Irom hospital)
ow should the patient's quality of life be considered?
CPR might also seem to lack beneIit when the patient's quality oI liIe is so poor that
no meaningIul survival is expected even iI CPR were successIul at restoring
circulatory stability. Judging "quality oI liIe" tempts prejudicial statements about
patients with chronic illness or disability. There is substantial evidence that patients
with such chronic conditions oIten rate their quality oI liIe much higher than would
healthy people. Nevertheless, there is probably consensus that patients in a permanent
unconscious state possess a quality oI liIe that Iew would accept. ThereIore, CPR is
usually considered "Iutile" Ior patients in a persistent vegetative state.
If CPR is deemed "futile," should a DNR order be written?
II CPR is judged to be medically Iutile, this means that you as the physician are under
no obligation to provide it. Nevertheless, the patient and/or their Iamily should still
have a role in the decision about a Do-Not-Resuscitate (DNR) order. This
involvement stems Irom respect Ior all people to take part in important liIe decisions,
commonly reIerred to as respect Ior autonomy or respect Ior person.
In many cases, the patient/Iamily, upon being given a caring but Irank understanding oI the
clinical situation, will agree with the DNR order. In such cases a DNR order can be written. Each
hospital has speciIic procedures Ior writing a valid DNR order. In all cases, the order must
be written or cosigned by the Attending Physician.


What if CPR is not futile, but the patient wants a DNR order?
As mentioned above, a decision to withhold CPR may also arise Irom a patient's
expressed wish that CPR not be perIormed on her. II the patient understands her
condition and possesses intact decision making capacity, her request should be
honored. This position stems Irom respect Ior autonomy, and is supported by law in
many states that recognize a competent patient's right to reIuse treatment.
What if the family disagrees with the DNR order?
Ethicists and physicians are divided over how to proceed iI the Iamily disagrees. At
the UW, Harborview, and JA Medical Centers, the policy is to write a DNR order
only with patient/family agreement.
II there is disagreement, every reasonable eIIort should be made to communicate with
the patient or Iamily. In many cases, this will lead to resolution oI the conIlict. In
diIIicult cases, an ethics consultation can prove helpIul. Nevertheless, CPR should
generally be provided to such patients, even iI judged Iutile.
What about "slow codes"?
It is the policy oI the UWC, arborview and VA that so-called "slow-codes," in
which a halI-hearted eIIort at resuscitation is made, are not ethically justiIied. These
undermine the right patients have to be involved in inpatient clinical decisions, and
violates the trust patients have in us to give our Iull eIIort.
What if the patient is unable to say what his/her wishes are?
In some cases, the decision about CPR occurs at a time when the patient is unable to
participate in decision making, and hence cannot voice a preIerence. There are two
general approaches to this dilemma: Advance Directives and surrogate decision
makers.
O dvance Directive: This is a document which indicates with some speciIicity
the kinds oI decisions the patient would like made should he be unable to
participate. In some cases, the document may spell out speciIic decisions
(e.g. Living Will), while in others it will designate a speciIic person to make
health care decisions Ior them (i.e. Durable Power of ttorney for ealth
Care). There is some controversy over how literally living wills should be
interpreted. In some cases, the document may have been draIted in the distant
past, and the patient's views may have changed. Similarly, some patients do
change their minds about end-oI-liIe decisions when they actually Iace them. In
general, preIerences expressed in a living will are most compelling when they
reIlect long held, consistently stable views oI the patient. This can oIten be
determined by conversations with Iamily members, close Iriends, or health care
providers with long term relationships with the patient.
O $urrogate decision maker: In the absence oI a written document, people close
to the patient and Iamiliar with his wishes may be very helpIul. The law
recognizes a hierarchy oI Iamily relationships in determining which Iamily
member should be the oIIicial "spokesperson," though generally all close
Iamily members and signiIicant others should be involved in the discussion and
reach some consensus. The hierarchy is as Iollows:
1. Legal guardian with health care decision-making authority
2. Individual given durable power oI attorney Ior health care decisions
3. Spouse
4. Adult children oI patient (all in agreement)
5. Parents oI patient
6. Adult siblings oI patient (all in agreement)