This paper examines Do-Not-Resuscitate (DNR) orders and their role in end-of-life medical decision-making. It explains the clinical scope of CPR and the circumstances under which DNR orders apply, drawing on real-world cases to illustrate why advance directives matter. The paper also addresses ethical considerations rooted in both medical practice and religious values, outlines the legal standards governing a physician's assessment of patient decision-making capacity, and provides practical guidance on how competent adults can document their healthcare wishes. Overall, the paper argues that every adult should proactively consider and formalize their end-of-life care preferences before a crisis arises.
A Do-Not-Resuscitate (DNR) order from an adult patient directs medical staff not to attempt to restore the patient's breathing or heartbeat if either has ceased. This means that doctors, nurses, and other healthcare practitioners will not initiate emergency procedures such as mouth-to-mouth resuscitation, external chest compression, electric shock, insertion of a tube to open the airway, injection of medication into the heart, or open-chest cardiac massage. Additionally, the Health Care Proxy Law permits an adult patient to authorize another person to make decisions about DNR orders and other treatments if the patient is no longer capable of doing so.
Cardiopulmonary resuscitation (CPR) refers to the medical procedures used to revive a patient's heart and breathing when the patient experiences cardiac arrest. CPR may include relatively minor interventions such as mouth-to-mouth resuscitation and external chest compression. More advanced CPR may include electric shocks, insertion of a tube to open the patient's airway, injection of medication into the heart, and, in complex cases, open-chest cardiac massage. A DNR order instructs medical professionals not to perform CPR.
DNR orders may be written for patients who are in a hospital or nursing home, or for patients who are at home. A hospital DNR order informs medical staff not to resuscitate the patient if cardiac arrest occurs. If the patient is in a nursing home or at home, a DNR order informs staff and emergency medical personnel not to attempt urgent resuscitation and not to transfer the patient to a hospital for CPR.
Successful CPR restores heartbeat and breathing and may allow a patient to resume his or her previous lifestyle. The success rate of CPR depends on the patient's overall medical condition. Age alone does not determine whether CPR will succeed, although the illnesses and physical decline that often accompany aging can make CPR less effective. When patients are gravely or terminally ill, CPR may fail entirely or may only partially succeed, leaving the patient with brain damage or in a worse medical condition than before the cardiac arrest. In such cases, some patients prefer to be treated without aggressive resuscitation attempts. Under the Patient Bill of Rights, the decision whether to sign a Do-Not-Resuscitate order ultimately belongs to the adult patient.
The following cases illustrate why signing a DNR order — or more broadly, completing an advance directive — while one is healthy and competent is critically important.
Joe Ehman, a wheelchair-bound young man, was pressured by hospital staff to sign a Do-Not-Resuscitate order while he was still emerging from anesthesia. To resist the pressure, he had to summon the strength to shout, "I'm 30 years old. I don't want to die!" In 1993, Maria Matzik, a woman who sustained her life with the aid of a ventilator, fought back against nurses who demanded she sign a DNR order. When she refused, they told her that because she was on a ventilator, they would not assist her if she experienced cardiac arrest. She later credited her determination to resist that pressure with saving her life.
Perhaps the most widely known case is that of Terri Schindler-Schiavo. She collapsed in her Florida home and suffered a severe brain injury. A medical malpractice settlement had awarded funds for her care, but her husband subsequently blocked all attempts at treatment. For years, a legal battle raged between her husband, who sought court authorization to remove her feeding tube, and her parents, who fought to continue her care. Her parents' determination helped her survive two such attempts. This case illustrates that, had Terri documented her wishes in a legally binding living will, years of family conflict and legal proceedings might have been avoided, and her own preferences — whatever they were — would have been honored.
All adults have the right to make their own medical decisions and to record those decisions in legally binding documents. Consulting a doctor and an attorney to formalize these wishes can prevent enormous personal, legal, and family difficulties.
"Religious and moral dimensions of end-of-life choices"
"Physician legal standards for assessing patient capacity"
"Practical steps for adults documenting DNR wishes"
Patients with DNR orders may be suitable candidates for anesthesia, surgery, or certain other procedures intended to facilitate care or relieve pain. These procedures may generate acute life-threatening situations requiring invasive airway management, assisted ventilation, or defibrillation. The fact that cardiopulmonary arrest is more likely to be reversible when it occurs during anesthesia or surgery often means that it may be in the patient's best interest to have the DNR order suspended during the intraoperative and immediate postoperative period. Patients admitted with durable DNR orders will have those orders honored by entering the DNR into the medical record and recording the relevant order form number. These orders remain in force until revoked by the patient or the patient's surrogate.
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