Understanding Do Not Resuscitate (DNR) Orders

CPR is a vigorous emergency procedure and it is not always successful. Experience has shown that CPR does not restore breathing and heart function in patients who have widespread cancer, widespread infection or other terminal illness. 

A patient may not want CPR attempted when:

• There is no medical benefit expected. CPR wasn't meant for people who are terminally ill or have severe health problems. CPR is not likely to be successful for these people.
• Quality of life would suffer. Sometimes CPR is only partly successful. Though the patient survives, they may suffer damage to the brain or other organs or permanently may be dependent on a machine to breathe. This can be particularly true for the elderly and very frail.
• Death is expected soon. Persons with terminal illness may not want aggressive interventions but prefer a natural peaceful death.

Patients have the legal and moral right to accept or refuse medical treatments, including CPR. Like many aspects of health care, the decisions about treatment are made together by the patient (or when a patient is unable to speak for him/herself, a health care proxy or family member) and the physician and other health care providers.

Basic CPR includes vigorous chest compressions to restore heart function and mouth-to-mouth breathing to restore lung function. 

Advanced CPR offers additional interventions which can include:

• Intubation - The insertion of a tube into the mouth or nose to help with breathing.
• Mechanical Ventilation - The use of a machine to move air into the lungs.
• Medications - Given through a vein, drugs can help with blood pressure regulation, heart rhythm, and blood flow.
• Cardioversion - The use of a controlled electrical shock to change heart rhythm.

Like all health care decisions, a decision about resuscitation should be based on a combination of your own values and preferences together with the medical facts and options for treatment. This should occur in a conversation with your physician and other health care providers that you know and trust. Talk to your doctor about what he/she would recommend, knowing you and your condition. Think about what is important to you and talk to family members and friends. It may be helpful to seek counseling from clergy, therapists or social workers, especially when you are making a decision for someone else.

To change a DNR orders, talk to your physician. Because the DNR orders are a physician's order, the physician must be involved to change it.

No, not without a specific discussion about it. All other medically indicated treatment is continued, unless you decide to limit it.

No. There is a special form that must be filled out for the DNR orders to be honored in the community. The form is issued to physicians from the Department of Public Health (DPH) and is called the Massachusetts DPH Comfort Care/DNR orders Verification Form. Ask your physician if you want to complete one.

If you are unable to communicate your wishes, the health care team relies on your advance care directives (such as a health care proxy or living will). If these are unavailable, a family member is asked to make decisions for you, based on what he/she believes are your wishes.

Talk to your physician, nurse or other members of your health care team. If you are not currently an inpatient at Brigham and Women's Faulkner Hospital, please contact your regular primary care physician (PCP) for more information about DNR orders.

Cardiac Chest Compression:
The force applied by pressing with both arms over the mid-chest to restore circulation of blood by the heart. Because a great deal of force is needed, there can be injury to the surrounding area as a result. 

CPR:
Cardiopulmonary Resuscitation: The vigorous emergency procedure to restore heart and lung function in someone whose heart or lungs have stopped working. Basic CPR involves chest compression and mouth-to-mouth breathing. Advanced CPR includes the use of medications to regulate blood pressure and heart rhythm, controlled electrical shock to change heart rhythm, and intubation and mechanical support of breathing.

DNR order:
The physician's order to withhold resuscitation. No CPR.

DPH Comfort Care/DNR:
The Massachusetts Department of Public Health document that verifies to emergency medical personnel that the person does not want resuscitation. 

Cardioversion or Defibrillation:
The use of controlled electrical shock to treat certain kinds of heart rhythm problems. 

Intubation:
A tube inserted through the mouth or nose to open the person's airway to assist with breathing. Intubation prevents a patient from talking or eating by mouth.

Mechanical Ventilation:
The use of a machine that pumps air into the lungs of a person who is unable to breathe on his/her own. 

Medications for Advance Life Support:
The use of very potent medications given through the veins that help to correct problems with blood pressure ("pressors"), heart rate and rhythm.

Resuscitation:
The use of basic or advanced life support treatments in an emergency situation begun when someone has stopped breathing or whose heart has stopped beating.