Nethra Vijayanand
IB Y1 B
16th December 2022
What is a DNR?
A DNR order stands for do-not-resuscitate order and it is a medical order written by a doctor. It instructs health care providers to not perform cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating.
What is Resuscitation?
CPR is the treatment given when a patient's blood flow or breathing stops.It may involve:
Chest compressions: Pushing down on the chest repeatedly to aid in maintaining blood flow throughout the body until heart function is restored.
Intubation: Inserting an endotracheal tube through the mouth and into the airway. This tube is connected to a ventilator, which pushes air into the lungs.
Cardioversion: Corrects abnormal heart rhythms using a set of paddles to deliver an electrical shock to the heart or via medication.
IV medications: Medications that are sometimes used in the case of cardiac arrest include epinephrine, amiodarone, vasopressin, and atropine sulphate.
Why are DNR orders used?
Common reasons that people decide to give a DNR include:
Religious or philosophical beliefs that go against resuscitation
Failing health-serious chronic illnesses like congestive heart failure or COPD
Failure to respond to any medical treatment
Diminished quality of life-increasing dependence on others for basic daily needs or stuck in the hospital for a prolonged period of time whilst receiving life-sustaining treatment.
Furthermore, we tend to overestimate the success of CPR especially because CPR is almost always portrayed to be a key in healing patients completely on tv and in movies.Yet, in reality, even though CPR undoubtedly increases chances of survival significantly, only 10% to 20% of people actually survive after cardiac arrest outside the hospital.Even if a person survives after CPR, they usually encounter several health problems and require even more treatment.Examples include:
Brain damage
Heart damage
Lung injury
Internal bleeding
Broken ribs
As a cause of all these consequences,Some patients decide to get DNRs as they are against the idea of being on life support in the hospital during their last few days.They'd rather be at their own place with their loved ones, rather than having a diminished quality of life because of the further complications of CPR.
What are the types of orders?
A DNR order has alternative names as well but it conveys just the same instruction that is to NOT resuscitate.The other two names for this order are:
No code: To distinguish a do-not-resuscitate order from a "full code" or "code blue," both of which mean every effort should be made to resuscitate a patient.
Allow natural death (AND) orders: Whilst a DNR simply states that no attempt should be made to restart the heart or breathing if it stops, an AND order ensures that the natural dying process is permitted to occur while assuring maximum comfort.Thus, this would mean stopping artificial feedings, fluids, and other measures that would push away a natural death.These orders are mostly used for terminally ill patients.
What happens if you are unable to make or discuss a DNR order in advance of your heart stopping?
In this case, the doctor should check if the patient has an Advance Decision to Refuse Treatment (ADRT) that declares that they wish to refuse CPR. Next, the doctor will check if the patient has a Lasting Power Of Attorney (LPA) which will aid doctors with the decision making in regards to life-sustaining treatments .
The doctor must also ask the patient's loved ones about their wishes and preferences. This includes anyone who had the legal power to represent the patient, such as a personal welfare deputy or if the patient is under 16- it would be a parent representing.If the patient doesn't have anyone appropriate to represent them, the doctor should request an independent mental capacity advocate (IMCA) to represent the patient in the decision-making process on whether to give a DNR order or not. The doctor should also ensure to ask members of the patient's healthcare (multidisciplinary) team for their views.
What are the ethical complications of DNR orders?
DNR orders are banned in some countries because they go against the country's main religious beliefs or their philosophical beliefs.Furthermore, DNR is generally viewed as controversial and has several disadvantages.Examples of disadvantages include:
the DNR discussion may be very limited and the patients' personal preferences may not be respected everywhere,
the patient lacks capacity to voice out what exactly they want
the medical staff fail to supply appropriate and adequate information to the patient for decision-making etc.
Plus, researchers are just discovering that the majority doctors and nurses misconstrue DNR to mean that the patient only desires end-of-life care whilst DNR only forbids on thing: resuscitation.This can lead to severe consequences because some medical staff have been recorded to not take DNR patients to the ICU even when they require intensive care.This can lead to a much quicker death than what the patient initially wanted.
An important point to note:
A DNR order can be revoked very easily, it's enough if the patient just notifies their attending physician and the DNR order will be removed from their medical record.
Citations:
“Can a DNR Be Revoked by Family?” Trust & Will, trustandwill.com/learn/can-a-dnr-be-revoked-by-family.
Fan, Sheng-Yu, et al. “Allow Natural Death versus Do-Not-Resuscitate: Titles, Information Contents, Outcomes, and the Considerations Related to Do-Not-Resuscitate Decision.” BMC Palliative Care, vol. 17, no. 1, 10 Oct. 2018, 10.1186/s12904-018-0367-4.
https://www.facebook.com/verywell. “When to Choose and How to Implement a “Do Not Resuscitate” Order.” Verywell Health, 2019, www.verywellhealth.com/hands-off-do-not-resuscitate-1132382.
Investor's Business Daily. “Do Not Sign a DNR before You Read This.” Investor’s Business Daily, 28 Mar. 2018, www.investors.com/politics/columnists/do-not-resuscitate-dnr-orders-dangerous-for-patients/.
MedlinePlus. “Do-Not-Resuscitate Order: MedlinePlus Medical Encyclopedia.” Medlineplus.gov, 2018, medlineplus.gov/ency/patientinstructions/000473.htm.
NHS. “Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Decisions.” Nhs.uk, 10 Mar. 2021, www.nhs.uk/conditions/do-not-attempt-cardiopulmonary-resuscitation-dnacpr-decisions/.
“What Is a Do-Not-Resuscitate (DNR) Order? Why Is It Used?” GoodRx, www.goodrx.com/healthcare-access/patient-advocacy/dnr-order-do-not-resuscitate.
“Write Your Legal Will Online, Free & Simple.” FreeWill, www.freewill.com/learn/what-is-a-dnr-order.
Fan, Sheng-Yu, et al. “Allow Natural Death versus Do-Not-Resuscitate: Titles, Information Contents, Outcomes, and the Considerations Related to Do-Not-Resuscitate Decision - BMC Palliative Care.” BioMed Central, BioMed Central, 10 Oct. 2018, https://bmcpalliatcare.biomedcentral.com/articles/10.1186/s12904-018-0367-4.
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