Do Not Resuscitate Orders: Ethics, Law, and Patient Rights

Introduction to Do Not Resuscitate Orders

First used about fifty years ago, the do not resuscitate (DNR) order continues to elicit questions and discussion among medical experts and patients. The DNR order is a directive from a patient who specifically refuses consent for certain forms of medical interventions related to life-saving actions by hospital personnel. The presence of a DNR order makes it important that informed discussions between a specific patient, family, physicians, and staff are conducted regarding the patient's medical conditions. In the modern world, advances in medical therapy — including end-of-life treatments — have made the presence of a DNR order even more crucial.

Epidemiological research has greatly enhanced our knowledge of the different forms and outcomes of resuscitation. However, it is the physicians, patients, and institutional (hospital) policies that greatly influence the occurrence of DNR orders (Loertscher, Reed, Bannon, & Mueller, 2010).

A do not resuscitate order records the patient's directive to rule out the use of cardiopulmonary resuscitation (CPR) should circumstances arise in which the patient becomes unresponsive or apneic, with or without a heartbeat. A DNR order must be in written form. The DNR order also prohibits other kinds of resuscitation interventions, including chest compressions, rescue breathing, defibrillation, and the use of sophisticated cardiovascular life support systems.

The DNR order instructs healthcare providers not to introduce a tube into the patient and initiate mechanical ventilation in the event of acute respiratory distress or sleep apnea. The order may only be given by patients who have severe chronic conditions that cannot improve, or by those who are receiving end-of-life treatment. It prevents the caregiver from intervening to resuscitate a patient who is not breathing or does not have a heartbeat. A DNR order, however, does not prevent other forms of medical intervention. A patient can cancel a DNR order at any time (Barlow, 2014).

DNR Orders vs. Living Wills and Power of Attorney

A power of attorney is a written legal document that grants an appointed individual or board authority over certain affairs in the event that the individual becomes incapacitated. The durable power of attorney (DPOA) authorizes the appointed individual to carry out bank transactions, sign social security documents, and/or sign checks to pay bills. These legal documents allow specific appointees to act on one's behalf in particular cases. For example, one individual can be given a medical power of attorney while another is appointed with a legal and/or financial power of attorney (Nabili, 2015).

A living will, on the other hand, is a written record that gives directives on what kinds of medical interventions may be initiated in the event that one becomes incapacitated. The living will can be general or precise. The most prevalent statement in a living will is typically that if one suffers an incurable, terminal illness as determined by a physician, then the individual directs that all life-sustaining interventions that might prolong life are to be prohibited, suspended, or stopped (Nabili, 2015).

Under New York State law, a do not resuscitate order directs medical caregivers not to initiate cardiopulmonary resuscitation — that is, emergency intervention to restart the heart or lungs — in the event that such care is needed. This order instructs physicians, nurses, and/or paramedics not to provide emergency treatments including intubation to open the airways, chest compressions, electric shock, injection of drugs into the heart or chest, or even basic mouth-to-mouth resuscitation.

In New York State, any person who is 18 years of age or older can obtain either a Hospital or Non-Hospital DNR order. A Hospital DNR order is given if one is in a healthcare facility such as a hospital or hospice registered by the State. Paramedics are under obligation to respect a Hospital DNR order during transit to or from the hospital. However, if one is not in any of these facilities, then one should obtain a Non-Hospital DNR order (Schneiderman).

Effects on Healthcare Providers and Family Members

The instruction to prevent resuscitation is atypical in the medical profession because it is the only treatment decision that must be made prior to the occurrence of the event. In the absence of a DNR order, the physician and all caregivers are required to initiate CPR whenever the heart stops, even in cases where it is apparent that this is not the best option. Therefore, all staff must be made aware if a DNR order has been issued. Ultimately, because patient autonomy must be prioritized in these decisions, there is a need for patients to be fully informed (Lofmark).

Before DNR orders became available and routine, most physicians followed a more paternalistic approach. Many clinical choices were made solely on the physician's medical judgment, without consultation with patients. This was generally accepted by most patients, and long-term prognoses were often only disclosed if a patient asked. Over time, it became clear that many of the choices physicians faced were not purely medical but also encompassed personal and moral values affecting both patients and physicians. Today, patient autonomy has been prioritized and patients' rights to be informed have been strengthened. Knowledge of ethical principles in medical practice has become widespread, and older ethical principles have been redefined to fit the modern context. In addition to autonomy, principles such as non-maleficence, beneficence, and justice are taken into account, alongside professional virtues including integrity, responsibility, truthfulness, fairness, persistence, courage, discernment, faithfulness, and conscientiousness (Beauchamp, 1994).

Studies have examined the experiences of caregivers, particularly nurses, with respect to DNR orders. One study found that approximately 10% of patients who gave DNR orders were prompted to do so by nurses. Research conducted in the Netherlands reported that 20% of nurses disagreed with the DNR decisions of 68 out of 148 patients. A study conducted in the United States reported that half of the nurses surveyed said they had carried out duties that conflicted with their personal principles when caring for terminally ill patients. Among house officers, approximately 70% reported similar experiences, many citing what they described as "overly burdensome" therapies. Nearly half of the physicians were satisfied with the level of patient involvement in treatment decisions, compared with only 25% of the nurses. Furthermore, only 20% of the nurses were satisfied with the way in which patients' wishes were documented in medical records (Lofmark).

Several authors have examined the perspectives of family members before and after the death of a loved one. In one study, 461 family members were asked for their views on treatment and decision-making during their loved one's last month of life. Of these, 23% could not recall any consultation on the treatment decision; 44%, the majority, stated that they desired increased communication; and a further 17% had asked for more time with the physician (Hanson & Garrett, 1997). A separate American study involving 32 relatives found that they requested prior planning, timely communication, a clearly defined role for family members, facilitation of harmony within the family, and acknowledgment of the family's grief. Actions that made relatives feel excluded or caused them additional grief were not appreciated, including: postponing consultations on withdrawal of treatment, hesitation in enacting withdrawal once it had been agreed upon, entrusting the decision-making process to only one relative, and framing death as a failure (Lofmark).