To be, or not to be (Do Not) Resuscitated: that is the question

What does it mean to be Do Not Resuscitate (DNR)?

The more informative question is, what does it look like to be resuscitated?

A resuscitation is attempted when your heart is not beating and you are not breathing. In other words, you are dead. Once your heart stops beating, blood is not flowing to your brain to provide essential oxygen. It is then a matter of minutes before the lack of oxygen will cause brain damage. During cardiopulmonary resuscitation (CPR), regular compressions are applied to your chest that are deep and forceful enough to push down on the heart below and cause it to pump blood to your body. Additionally during CPR, electric shocks are administered at regular intervals to the heart to try to “jump start” it so that it can resume its vital function of regular beating to get blood flowing to your body. During a resuscitation, breathing tubes may be inserted into you to open the airway and medications may be used to control your heart.

When is a resuscitation attempted?

There are two general scenarios when a resuscitation may be attempted. One, is in a hospital setting, where doctors are taking care of a person and generally know what is wrong with them, but that person has an unexpected, but not surprising, cardiac arrest. Examples of this may be someone with a major infection, a bad stroke, or end stage cancer. The other scenario when a resuscitation may be attempted is in the “community setting,” where a person is going about their business and has an unexpected cardiac arrest at home or other non-hospital setting.

In the first scenario, doctors and families often have had time to discuss the person’s condition, can anticipate if that person might arrest soon, and decide in advance whether they should attempt resuscitation in the event of an arrest. In the second scenario, the arrest is unexpected and the people performing the resuscitation have just a few seconds to determine whether to attempt it. If a person’s resuscitation wishes are unknown and paramedics are called, they will perform CPR (more on that below).

What is the success rate of a resuscitation?

Unfortunately, CPR is not as effective in real life as portrayed in the movies. Even if the heart is restarted, the patient remains very unstable and has a high risk of dying within the next few days. Their odds are better depending on their age, overall health, and the underlying reason for the arrest. If the arrest happens in the community setting and a pulse is restored, the patient is then transported to the hospital (usually the ICU) for care and their survival rate to leave the hospital is only 10%¹. Though better, only 25% of patients who have CPR in the hospital survive to leave the hospital.

What is a Do Not Resuscitate (DNR) order?

A Do Not Resuscitate (DNR) order is a medical order, signed by a physician (or nurse practitioner in some states), that instructs healthcare workers NOT to resuscitate a person who has had a cardiac arrest. The order must be chosen by the patient or their medical Power of Attorney (POA) if the patient is no longer able to make their own decisions. If a person does not have a DNR order, by default, medical personnel, including paramedics, will always attempt a resuscitation.

How do paramedics and other healthcare workers know whether someone has a DNR order?

At the time of the arrest, the healthcare workers need to be presented with a signed DNR order to NOT attempt CPR. Otherwise, by default, they will attempt a resuscitation. Therefore, all patients admitted to the hospital are asked whether they have a DNR order and it is noted in their chart. For people who desire for their DNR order to be honored in a community setting (at their home, etc.), they must have the order prominently displayed so that it is known they have such an order. Paramedics will not spend more than a few moments looking for the form so it needs to be somewhere extremely visible such as posted in the front entrance or on the fridge. They will not look in drawers or in a safe. Some patients will order a DNR medical bracelet. A tattoo cannot act as a DNR order.

Who should have a DNR order?

At some point in your life, you may decide to become DNR so that if your heart stops beating, you allow nature to run its course and allow a “natural” death (one without aggressive medical interventions). The decision to become DNR is a personal one.

When someone is in their 90s, lives in a nursing home, has dementia, and is bed-bound, the decision might seem easy. If that person is found dead, most would agree, they would not want be resuscitated. A peaceful death at an older age is not a guarantee, but you can make decisions that allow you to have that kind of death and one of those decisions is a DNR order. Similarly, if a person is at the end of a long chronic illness, such as cancer, many would not want to have an attempted resuscitation as they could only be brought back to decline again.

And in the opposite situation, most would agree, a young healthy person in their 20s should have an attempted resuscitation if they should suffer a cardiac arrest. A younger, healthy person is also more likely to have a better outcome from CPR than someone older who is in poor health.

The time between those two extremes depends on one’s overall general health, age, personal feelings, discussions with family and doctors, and their “Litmus Test” [read more on that here].

Now many patients will say, I want to be resuscitated if you can save me. The truth is, in these sudden situations, we do not know why a person dies. It could be a massive heart attack, a large blood clot, a ruptured aneurysm, a cardiac arrhythmia, or a multitude of problems. Until someone arrives at the hospital, we do not know how treatable the condition is.

If you are unsure, I typically tell patients to forgo a DNR order, but have detailed discussions with their family members and develop a solid Litmus Test. That way, your medical power of attorney can make medical decisions with your wishes in mind. Also recall that even if a person is resuscitated, their chance of survival to hospital discharge is quite low anyway.

How do I make a DNR order?

You create a DNR order with your physician, or nurse practitioner in some states. Schedule an appointment just to have this discussion and ask all your questions. Once you sign a DNR order, your physician will keep a copy and you should keep a copy. Your copy should be prominently displayed in your home in case paramedics need to see it upon entry to your home. You also want to give a copy to your medical power of attorney, and keep a copy with your estate documents. Some states have a database where you can upload your advance directive and DNR order. Always bring a copy of your DNR order with you when you go to the hospital.

What if I want to revoke my DNR order?

You can always recall your DNR order. If you would like to revoke your DNR order, just tear it up or write “VOID” over it. Be sure all the copies are also destroyed and you update your medical power of attorney and other key people in your life.

Can my family change your DNR order?

Generally, doctors try to follow the patient’s wishes to the best of their ability. Your family can revoke your DNR order, but if doctors really feel this is not your wish and not in your best interest, they can escalate the decision to a hospital Ethics Committee for further discussion.