Do not resuscitate

Do Not Resuscitate (DNR), also known as no code or allow natural death, is a legal order written either in
the hospital or on a legal form to withhold cardiopulmonary resuscitation (CPR) or advanced cardiac life
support (ACLS), in respect of the wishes of a patient in case their heart were to stop or they were to stop
breathing. The DNR request is usually made by the patient or health care power of attorney and allows
the medical teams taking care of them to respect their wishes. In the health care community, allow
natural death (AND) is a term that is quickly gaining favor as it focuses on what is being done, not what
is being avoided.[citation needed] Some criticize the term "do not resuscitate" because of the
implication of important information being withheld, while research shows that only about 5% of
patients who require CPR outside the hospital and only 15% of patients who require CPR 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 and Do Not Resuscitate are common terms in the United States, Canada, New Zealand and the
United Kingdom. This 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. Hospitals sometimes use
the expression no code, which refers to the jargon term code, short for Code Blue, an alert a hospital's
resuscitation team.

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.[4]
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.

Resuscitation orders, or lack thereof, can also be referred to in the United States as a part of Physician
Orders for Life Sustaining Treatment (POLST) or Medical Orders for Life Sustaining Treatment (MOLST)
orders[5], typically created with input from next of kin when the patient or client is not able to
communicate their wishes.

Another synonymous term is "not to be resuscitated" (NTBR).[6]

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 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 their wish, as neither an advance
directive nor a living will is a legally binding document.

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.[7]

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.[8]

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.[9] 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.[10]

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.[11] One study reported that physicians repeatedly give high intensity care to patients
while deciding they themselves would be DNR under similar circumstances.[12]

There is also the ethical issue of discontinuation of an implantable cardioverter defibrillator (ICD) 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.[13]

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.[14] 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.[15] 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.

United Kingdom

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.[16] 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.[17]

United States

In the United States the documentation is especially complicated in that each state accepts different
forms, and advance directives and living wills may not be accepted by EMS as legally valid forms. If a
patient has a living will that specifies the patient requests of DNR but does not have a properly filled out
state-sponsored form that is co-signed by a physician, EMS may 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.[18] 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.[19][20]

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.[21]
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.[21]

Australia

In Australia, Do Not Resuscitate orders are covered by legislation on a state-by-state basis.

In Victoria, a Refusal of Medical Treatment certificate is a legal means to refuse medical treatments of
current medical conditions. It does not apply to palliative care (reasonable pain relief; food and drink).
An Advanced Care Directive legally defines the medical treatments that a person may choose to receive
(or not to receive) in various defined circumstances. It can be used to refuse resuscitation, so as avoid
needless suffering.[22]

In NSW, a Resuscitation Plan is a medically authorised order to use or withhold resuscitation measures,
and which documents other aspects of treatment relevant at end of life. Such plans are only valid for
patients of a doctor who is a NSW Health staff member. The plan allows for the refusal of any and all
life-sustaining treatments, the advance refusal for a time of future incapacity, and the decision to move
to purely palliative care.[23]

Italy

DNRs are not recognized by Italy. Physicians must attempt to resuscitate all patients regardless of
individual or familial wishes. Italian laws force healthcare staff to resuscitate a patient even if the patient
has a DNR or does not wish to live. There are jail penalties (from 6 to 15 years) for healthcare staff
breaching this law, e.g. "omicidio del consenziente"[24][better source needed] - Link is in Italian.
Therefore in Italy a signed DNR has no legal value.

References

1. Jump up^ Fairbanks RJ, Shah MN, Lerner EB, Ilangovan K, Pennington EC, Schneider SM
(March 2007). "Epidemiology and outcomes of out-of-hospital cardiac arrest in
Rochester, New York". Resuscitation. 72 (3): 415–
24. doi:10.1016/j.resuscitation.2006.06.135. PMID 17174021.

2. Jump up^ Zoch TW, Desbiens NA, DeStefano F, Stueland DT, Layde PM (July 2000).
"Short- and long-term survival after cardiopulmonary resuscitation". Arch. Intern.
Med. 160 (13): 1969–73. doi:10.1001/archinte.160.13.1969. PMID 10888971.

3. Jump up^ Ehlenbach WJ, Barnato AE, Curtis JR, et al. (July 2009). "Epidemiologic study of
in-hospital cardiopulmonary resuscitation in the elderly". N. Engl. J. Med. 361 (1): 22–
31. doi:10.1056/NEJMoa0810245. PMC 2917337. PMID 19571280.

4. Jump up^ Alternative to "DNR" Designation: "Allow Natural Death" - Making Sense in
the Health Care Industry.

5. Jump up^ Pollak, Andrew. Emergency Care and Transportation of the Sick and Injured.
Jones & Bartlett Learning, 2017, isbn 978-1-284-10690-9, Page 540.

6. Jump up^ Vincent JL, Van Vooren JP (Dec 2002). "[NTBR (Not to Be Resuscitated) in 10
questions]". Rev Med Brux. 23 (6): 497–9. PMID 12584945.
7. Jump up^ Dugan D, Riseman J. Do-Not-Resuscitate Orders in an Operating Room Setting
#292. Journal of Palliative Medicine [serial online]. July 2015;18(7):638-639.

8. Jump up^ Garrido M, Harrington S, Prigerson H. End-of-life treatment preferences: A

key to reducing ethnic/racial disparities in advance care planning?. Cancer (0008543X)
[serial online]. December 15, 2014;120(24):3981-3986.

9. Jump up^ Humble M. Do-Not-Resuscitate Orders and Suicide Attempts. National

Catholic Bioethics Quarterly [serial online]. Winter2014 2014;14(4):661-671.

10. Jump up^ Hébert P, Selby D. Should a reversible, but lethal, incident not be treated
when a patient has a do-not-resuscitate order?. CMAJ: Canadian Medical Association
Journal [serial online]. April 15, 2014;186(7):528-530.

11. Jump up^ Capone R. PROBLEMS WITH DNR AND DNI ORDERS. (Cover story). Ethics &
Medics [serial online]. March 2014;39(3):1-3.

12. Jump up^ Physicians provide high-intensity end-of-life care for patients, but "no code"
for themselves. Medical Ethics Advisor Volume: 30 Issue 10 (2014) ISSN 0886-0653

13. Jump up^ Daeschler M, Verdino RJ, Caplan AL, Kirkpatrick JN (2015). "Defibrillator
Deactivation against a Patient's Wishes: Perspectives of Electrophysiology
Practitioners". Pacing and Clinical Electrophysiology. 38 (8): 917–
924. doi:10.1111/pace.12614.

14. Jump up^ "Mideast med-school camp: divided by conflict, united by profession". The
Globe and Mail. August 2009. Retrieved 2009-08-22. In hospitals in Jordan and Palestine,
neither families nor social workers are allowed in the operating room to observe
resuscitation, says Mohamad Yousef, a sixth-year medical student from Jordan. There
are also no DNRs. “If it was within the law, I would always work to save a patient, even if
they didn't want me to,” he says.

15. Jump up^ "Nurses deny knowledge of 'do not resuscitate' order in patient's
death". thenational.ae. Retrieved 12 April 2018.

16. Jump up^ "Decisions relating to cardiopulmonary resuscitation: A joint statement from
the British Medical Association, the Resuscitation Council (UK) and the Royal College of
Nursing" (PDF). Resus.org.uk. Resuscitation Council (UK). Retrieved 17 June 2014.

17. Jump up^ Scottish Government (May 2010). "Do Not Attempt Cardiopulmonary
Resuscitation (DNACPR): Integrated Adult Policy" (PDF). NHS Scotland.

18. Jump up^ Eckberg, Evelyn (April 1998). "The continuing ethical dilemma of the do-not-
resuscitate order". AORN Journal. Retrieved 2009-08-23. The right to refuse or terminate
medical treatment began evolving in 1976 with the case of Karen Ann Quinlan v New
Jersey (70NJ10, 355 A2d, 647 [NJ 1976]). This spawned subsequent cases leading to the
use of the DNR order.(4) In 1991, the Patient Self-Determination Act mandated hospitals
ensure that a patient's right to make personal health care decisions is upheld. According
 to the act, a patient has the right to refuse treatment, as well as the right to refuse
resuscitative measures.(5) This right usually is accomplished by the use of the DNR order.

19. Jump up^ "DO NOT RESUSCITATE – ADVANCE DIRECTIVES FOR EMS Frequently Asked
Questions and Answers". State of California Emergency Medical Services Authority.
2007. Archived from the original on 2009-08-23. Retrieved 2009-08-23. # What if the
EMT cannot find the DNR form or evidence of a MedicAlert medallion? Will they
withhold resuscitative measures if my family asks them to? No. EMS personnel are
taught to proceed with CPR when needed, unless they are absolutely certain that a
qualified DNR advance directive exists for that patient. If, after spending a reasonable
(very short) amount of time looking for the form or medallion, they do not see it, they
will proceed with lifesaving measures.

20. Jump up^ "Frequently Asked Questions re: DNR's". New York State Department of
Health. 1999-12-30. Retrieved 2009-08-23. May EMS providers accept living wills or
health care proxies? A living will or health care proxy is NOT valid in the prehospital
setting

21. ^ Jump up to:a b "Archived copy". Archived from the original on 2014-07-15.
Retrieved 2012-12-05.

22. Jump up^ "Respect for the right to choose - Resources". Dying with dignity, Victoria.
2017. Retrieved 2017-06-14.

23. Jump up^ "Using resuscitation plans in end of life decisions" (PDF). NSW government
health department. 2014-09-08. Retrieved 2017-06-14.

24. Jump up^ it:Omicidio del consenziente (ordinamento penale italiano)