What is a Do Not Attempt Resuscitation (DNAR) Order?

A Do Not Attempt Resuscitation (DNAR) Order, also known as a do not resuscitate

(DNR) order, is written by a licensed physician in consultation with a patient or
surrogate decision maker that indicates whether or not the patient will receive
cardiopulmonary resuscitation (CPR) in the setting of cardiac and/or respiratory
arrest. CPR is a series of specific medical procedures that attempt to maintain
perfusion to vital organs while efforts are made to reverse the underlying cause for
the cardiopulmonary arrest. Although a DNAR order may be a component of an
advance directive or indicated through advance care planning, it is valid without an
advance directive. (See Advance Care Planning and Advance Directives)

History of Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation Orders

The history of CPR and DNAR orders is extensively reviewed in the literature (Bishop
et al., 2010; Burns et al., 2003). In the 1960s, CPR was initially performed by
anesthesiologists on adults and children who suffered from witnessed cardiac arrest
following reversible illnesses and injuries. Based on the success of this intervention,
CPR became the standard of care for all etiologies of cardiopulmonary arrest and
the universal presumptive consent to resuscitation evolved (Burns et al., 2003).
However, in 1974, the American Heart Association (AHA) recognized that many
patients who received CPR survived with significant morbidities and recommended
that physicians document in the chart when CPR is not indicated after obtaining
patient or surrogate consent (ibid). This documentation formally became known as
the DNR order. Recent medical literature encourages reference to this
documentation as do-not-attempt-resuscitation (DNAR) and allow a natural death
(AND) based on the practical reality that performing CPR is an attempt to save life
rather than a guarantee (Venneman et al., 2008).

The Role of Patient Autonomy

Since the original inception of DNAR orders, respecting the rights of adult patients
and their surrogates to make medical decisions, otherwise known as respect for
autonomy or respect for persons, has been emphasized. This concept is reinforced
legally in the Patient Self Determination Act of 1991, which requires hospitals to

respect the adult patients right to make an advanced care directive and clarify
wishes for end-of-life care. In general, an emphasis on improving communication
with patients and families is preferred over physicians making unilateral decisions
based on appeals to medical futility regarding the resuscitation status of their
patients. See below.

What if patients are unable to express what their wishes are?

In some cases, patients are unable to participate in decision-making, and hence

cannot voice their preferences regarding cardiopulmonary resuscitation. Under
these circumstances, two approaches are used to ensure that the best attempt is
made to provide the patient with the medical care they would desire if they were
able to express their voice. These approaches include Advance Care Planning and
the use of surrogate decision makers. (See Advance Care Planning and Advance
Directives , and Surrogate Decision Makers)

Not all patients have Advance Care Plans. Under these circumstances, a surrogate
decision maker who is close to the patient and familiar with the patients wishes
may be identified. Washington state recognizes a legal hierarchy of surrogate
decision-makers, though generally close family members and significant others
should be involved in the discussion and ideally reach some consensus. Not all
states specify a hierarchy, so check your state law. Washingtons hierarchy is as
follows:

Legal guardian with health care decision-making authority

Individual given durable power of attorney for health care decisions
Spouse
Adult children of patient (all in agreement)
Parents of patient
Adult siblings of patient (all in agreement)
The surrogate decision maker is expected to make decisions using a substituted
judgment standard, which is based on what the patient would want if she could
express her wishes. In certain circumstances, such as in children who have not yet

developed decisional capacity, parents are expected to make decisions based on

the best of the patient, called a best interest standard.

When should CPR be administered?

In the absence of a valid physicians order to forgo CPR, if a patient experiences

cardiac or respiratory arrest, the standard of care is to attempt CPR. Paramedics
responding to an arrest are required to administer CPR. Since 1994 in Washington,
patients may wear a bracelet or carry paperwork that allows a responding
paramedic to honor a physician's order to forgo CPR. In the state of Washington, the
POLST form is a portable physician order sheet that enables any individual with an
advanced life-limiting illness to effectively communicate his or her wishes to limit
life-sustaining medical treatment in a variety of health care settings, including the
outpatient setting (Washington State Medical Association ).
Is CPR always beneficial?

The general rule of attempting universal CPR needs careful consideration

(Blinderman et al., 2012). Even though including patients and families in decisions
regarding resuscitation respects patient autonomy, providing patients and families
with accurate information regarding the risks and potential medical benefit of
cardiopulmonary resuscitation is also critical. Under certain circumstances, CPR may
not offer the patient direct clinical benefit, either because the resuscitation will not
be successful or because surviving the resuscitation will lead to co-morbidities that
will merely prolong suffering without reversing the underlying disease. Some
physicians and ethicists define CPR under these circumstances as medically
inappropriate or futile (Burns & Truog, 2007). Hence, evaluating both the proximal
and distal causes of the cardiac arrest is important when determining the likelihood
of successful resuscitation (Bishop et al., 2010; Blinderman et al. 2012). When CPR
does not have the potential to provide direct medical benefit, physicians may be
ethically justified in writing a DNAR order and forgoing resuscitation.

Defining Direct Medical Benefit

Determining the potential for direct medical benefit can be challenging, especially
when there is great uncertainty in outcome. One approach to defining benefit
examines the probability of an intervention leading to a desirable outcome.

Outcomes following CPR have been evaluated in a wide variety of clinical situations.
In general, survival rates in adults following in-hospital cardiac arrest range from 839% with favorable neurological outcomes in 7-14% of survivors (Meaney et al.,
2010). In children, the survival rate following in-hospital cardiac arrest is closer to
27% with a favorable neurological outcome in up to one third of survivors (AHA,
2010). Out of hospital arrest is less successful, with survival rates in adults ranging
from 7-14% and in infants and children approximately 3-9% (Meaney et al., 2010;
Garza et al., 2009). In general, these statistics represent the population as a whole
and do not necessarily reflect the chance of survival for an individual patient.
Hence, multiple factors, including both the distal and proximal causes for
cardiopulmonary arrest, must be considered to determine whether or not CPR has
the potential to promote survival (Bishop et al., 2010).

How should the patient's quality of life be considered?

CPR might appear to lack potential benefit when the patient's quality of life is so
poor that no meaningful survival is expected even if CPR were successful at
restoring circulatory stability. However, quality of life should be used with caution in
determining whether or not CPR is indicated or has the potential to provide medical
benefit, for there is substantial evidence that patients with chronic conditions often
rate their quality of life much higher than would healthy people. Quality of life
assessments have most credibility when the patients values, preferences, and
statements inform such assessments.

When can CPR be withheld?

Many hospitals have policies that describe circumstances under which CPR can be
withheld based on the practical reality that CPR does not always provide direct
medical benefit. Two general situations justify withholding CPR:

When CPR will likely be ineffective and has minimal potential to provide direct
medical benefit to the patient.
When the patient with intact decision making capacity or a surrogate decision
maker explicitly requests to forgo CPR.
How are DNAR Orders Written?

Prior to writing a DNAR Order, physicians should discuss resuscitation preferences

with the patient or his/her surrogate decision maker (Blinderman et al., 2012; Quill
et al., 2009). This conversation should be documented in the medical record,
indicating who was present for the conversation, who was involved in the decision
making process, the content of the conversation, and the details of any
disagreement.

These conversations are difficult and involve a careful consideration of the potential
likelihood for clinical benefit within the context of the patient's preferences.
Physicians can most effectively guide the conversation by addressing the likelihood
of direct benefit from cardiopulmonary resuscitation within the context of the overall
hopes and goals for the patient. They can then partner with the patient and his or
her family to determine the clinical interventions that most effectively achieve these
goals (Blinderman et al., 2012). This approach is described by the palliative care
literature as a goal oriented approach to providing end of life care.

If CPR is deemed "futile," should a DNAR order be written?

If health care providers unanimously agree that CPR would be medically futile,
clinicians are not obligated to perform it. Nevertheless, the patient and/or their
family still have a role in the decision about a Do Not Attempt Resuscitation (DNAR)
order. As described earlier, involving the patient or surrogate decision maker is
essential to demonstrate respect for all people to take part in important life
decisions.

In many cases, patients or surrogate decision makers will agree to forgo attempting
CPR following a transparent and honest discussion regarding the clinical situation
and the limitations of medicine. Under these circumstances, DNAR orders can be
written. Each hospital has specific procedures for writing a valid DNAR order.

What if CPR is not futile, but the patient wants a DNAR order?

In some cases, patients may request their desire to forgo attempting CPR at the
time of admission. Some of these patients may have an advanced care directive

that indicates their preferences to forgo attempting CPR. In other cases, a patient
may explicitly request CPR not to be performed. If the patient understands her
condition and possesses intact decision making capacity, her request should be
honored. This position stems from respect for autonomy, and is supported by law in
many states that recognize a competent patient's right to refuse treatment.

What if the family disagrees with the DNAR order?

Ethicists and physicians are divided over how to proceed if the family disagrees with
the recommendation to forgo attempting CPR.

If there is disagreement, every reasonable effort should be made to clarify questions

and communicate the risks and potential benefits of CPR with the patient or family.
In many cases, this conversation will lead to resolution of the conflict. However, in
difficult cases, an ethics consultation can prove helpful.

What about "slow codes" or show codes?

Slow codes and show codes are forms of symbolic resuscitation. A slow code is
an act performed by the health care providers that resembles CPR yet is not the full
effort of resuscitation while a show code is a short and vigorous resuscitation
performed to benefit the family while minimizing harm to the patient (Frader et al.,
2010). Slow and show codes are ethically problematic. In general, performing slow
and show codes undermines the rights of patients to be involved in clinical
decisions, is deceptive, and violates the trust that patients have in health care
providers.

Special Circumstances

There are special circumstances that should be considered and addressed in

patients with Do Not Attempt Resuscitation Orders. These circumstances primarily
arise when a patient undergoes anesthesia for surgical interventions or requires
urgent procedures. (See Do Not Resuscitate Orders during Anesthesia and Urgent
Procedures).

Advance Care Planning

Advance care planning is a process to help patients with decision-making capacity

guide future health care decisions in the event that they become unable to
participate directly in their care. The process, when accomplished comprehensively,
involves four steps: (1) thinking through one's relevant values and preferences, (2)
talking about one's values and preferences with ones spokesperson, close family
members and health care providers, (3) documenting them with an advance
directive, and (4) reviewing them periodically and updating them as needed. What
follows is a discussion of commonly asked questions related to the process of
advance care planning. (For related discussion, see also the topic pages on DNAR
Orders and End-of-Life Issues, Surrogate Decision-Making.)

How is advance care planning different from advance directives?

Advance care planning is the process as outlined above. Advance directives usually
are the written documents designed to allow competent patients the opportunity to
guide future health care decisions in the event that they are unable to participate
directly in medical decision making. (See discussion below of Advance Directives.
For related discussion, see Termination of Life-Sustaining Treatment.)

Verbal directives may be ethically valid, but most patients and health care providers
prefer written, official documentation. If official forms are not used, health care
providers should document the result of their advance care planning conversations
in a medical record progress note.

What are the goals and expected outcomes of advance care planning?

The goals of advance care planning are four-fold. These goals reflect respect for the
principles of patient autonomy (right to self-determination in light of personal
interests including goals, preferences, and concerns for ones family), beneficence
(promoting good) and non-maleficence (avoiding harm). In the event of decisional
incapacity, they are to:

Maximize the likelihood that medical care serves the patients goals,
Minimize the likelihood of over- or under-treatment,
Reduce the likelihood of conflicts between a patients spokesperson, family
members and health care providers, and
Minimize the burden of decision making on the spokesperson and/or family
members.
As a health care provider who engages her patients in advance care planning, you
can expect to better understand your patients views about who they want you to
communicate with when health care decisions are required and they can no longer
participate in decisions, their goals for medical treatment and care under situations
in which they cannot participate in decisions, their preferred approach to end-of-life
care, and their hopes (e.g., to live longer, to have quality relationships with loved
ones), as well as their fears about medical interventions (e.g., permanent loss of
cognitive functioning, loss of dignity). During the advance care planning process the
provider may want to discuss patient preferences for treatment and care if a patient
has an illness with known possible sequelae. For example, someone with mild
dementia may be able to state if she would want to receive antibiotics and be
hospitalized if she developed pneumonia at a time when she could no longer
provide self-care or recognize family members. In addition, you can expect to have
a discussion that clarifies misunderstandings. For example, patients often think that
cardiopulmonary resuscitation is successful 80% of the time, that mechanical
ventilation is a fancy word for nasal prongs, and that coma patients still have the
ability to enjoy life. These discussions also may reveal patients treatment
preferences that fall outside standard practices in medicine (e.g., herbal remedies,
medically futile treatments). When these occur, they provide opportunities to
negotiate about culturally sensitive approaches to health care and establish limits to
patient autonomy based on professional standards.

You can also expect to have better communication with patients family members or
loved ones because there should be enhanced shared understanding of patient
values and wishes. Thus, you can expect to have fewer conflicts with family
members about the approach to end-of-life care.

Advance directives will not be the outcome of most advance care planning.
However, advance care planning may lead to completion of a Physician Order for
Life Sustaining Treatment (POLST) form, an order that reflects the patients goals
and wishes for inpatient and outpatient medical care. (See Advance Directives and

Additional Readings below.) At a minimum, patients should become familiar with the
concept and rationale for advance care planning. Some patients will want to mull
things over, whereas others will want to discuss the topic with their close friends or
family and health care providers. Fewer will be ready to sign documents and even
fewer will be interested in personalizing their advance directives (e.g., attaching
additional information, such as worksheets that characterize values and
preferences) so that they are clear and contain pertinent information with clinical
relevance.

Who should I approach for advance care planning?

Unlike health promotional activities that are targeted to select populations based on
cost-effectiveness research, asking about interest in advance directives and
advance care planning has been recommended for newly admitted patients to
health care organizations. This is recommended by the Patient Self-Determination
Act of 1991 and The Joint Commission, and it has led to including a standard set of
questions at hospital admission.

When not systematically incorporated into a routine we often think of initiating

advance care planning with patients who are at higher risk for decisional incapacity.
If you practice in a setting that does not require routine advance care planning
discussions with patients (e.g., on hospital admission, biyearly), you should consider
having a conversation about this with patients with the following conditions:

At risk for strokes (e.g., those with hypertension)

Early dementia
Engaging in risky behavior that is associated with head trauma and coma (e.g.,
riding a motorcycle without a helmet, riding in cars without seat belts)
Debility/frailty (e.g., those at risk for delirium associated with an acute illness)
Severe, recurrent psychiatric illnesses
Chronic progressive and terminal illness
When and where should I initiate advance care planning?

It is unknown when or where advance care planning should ideally occur. It is

generally thought that this should occur initially in the outpatient setting, and then
be reviewed upon admission to and discharge from inpatient settings. It is also
recommended that whenever there is a significant change in a patient's social or
health status, the patient's views about advance care planning should be reviewed.

How can I raise these issues without scaring patients?

You can raise advance care planning as one of many health promotion activities.
These discussions are aimed at avoiding harms (over- and under-treatment), and
promoting benefits (treatments tailored to the patient's goals). You should reassure
the patient that raising this issue does not mean that there is something unspoken
to worry about. You also may tell the patient that this topic is difficult for many
patients and that you will understand if she does not want to come to any
conclusions during this discussion. You may want to refer the patient to one of
several reputable internet based advance care planning sites to stimulate further
thought and preliminary steps in advance care planning (see Additional Readings)

Are there some questions or aids that I could use for advance care planning?

When having a discussion about advance care planning, the following questions are
recommended:

Who should speak on your behalf if you become so sick you can't speak for
yourself?
Are there any circumstances that you've heard about through the news or TV where
you've said to yourself, "I hope that never happens to me or I would never want to
live like that?" If so, what are they and why do you feel this way about them?
For each of the circumstances that you just identified, what do you think should be
the goals for your care? For example, should the goal of care be to prolong your
life, improve or maintain your function and/or quality of life, provide comfort care, or
something else?
For other situations in which you would not be able to communicate your
preferences, such as [to be provided by the clinician], what do you think should be
the goals for your care? For example, should the goal of care be to prolong your life,

improve or maintain your function and/or quality of life, provide comfort care, or
something else?
Are there any life-sustaining treatments that you know you would want to receive
regardless of the circumstances, or would not want to receive under any
circumstances? If so, what are they and why do you feel this way about them?
Some people have more concerns about the way they will die or dying than death
itself. Do you have any fears or concerns about this?
In the event that you are dying, where do you want to receive your health care?
Should your current preferences be strictly applied to future situations or serve as a
general guide to your spokesperson or family member(s)?
An alternative approach after introducing the topic of advance care planning is to
suggest that the patient review an existing advance care planning educational
resource and utilize issues presented in its content to guide discussion and/or
worksheets when available to append to an advance directive. (See Additional
Readings)

How should I advise a patient if she doesn't have anyone to name as a proxy?

You should inform the patient that the best course of action under these
circumstances is to write down her wishes and give a copy to her health care
providers. She should fill out a legal form, such as a living will, with as much detail
as possible, and then include more detailed values and preferences to provide a
better understanding of her wishes. Copies of completed documents should be
provided to every health care clinic/facility where the patient receives care

How should I advise a patient if he believes that some family members will disagree
with his wishes?

The patient should be informed that the best way to prevent disagreements is to
communicate with everyone ahead of time to let them know who has been chosen
as a spokesperson and what kind of approach to health care he wants.

As a trainee, should I do advance care planning with my patients?

In the ideal doctor-patient situation the primary care physician should initiate
discussion when the patient is not acutely ill. However, this often is not the case and
therefore these discussions frequently occur in the hospital setting. Regardless of
the setting, good medical practice includes having these discussions. Thus, medical
students and residents should engage the patients they are caring for in these
discussions. If the patient has been recently diagnosed with a terminal or life
changing condition, has severe depression, demonstrates paranoid ideation, or is
suicidal, you should ask the responsible attending physician whether this is an
appropriate time to raise these issues. Otherwise, you should initiate the
discussions and request faculty support (such as role modeling or mentoring) if
needed. You should review the framing of the discussion and the patient's views
with the attending physician responsible for the patient's overall care.

Advance Directives

What types of advance directives are currently available?

Advance directives were officially inaugurated in 1977 with passage of the Natural
Death Act in California. The law allowed patients to direct their physicians to
withhold or withdraw life-sustaining treatment when they were terminally ill and
death was imminent. In 1992, Washington State passed a similar Natural Death Act.
Originally, it only applied to persons who were terminally ill and for whom death was
imminent. However, it was later amended to include persons in permanent
unconscious conditions and expanded to apply explicitly to discontinuation of
artificial hydration and nutrition.

A 1991 federal law, the Patient Self-Determination Act, requires that patients are
informed about their right to participate in health care decisions, including their
right to have an advance directive. Advance directives fall into two broad
categories: instructive and proxy. Instructive directives allow for preferences
regarding the provision of particular therapies or classes of therapies. Living wills
are the most common examples of instructive directives, but other types of
instructive directives, such as no transfusion and no CPR directives are also
employed. The proxy directive, generally a Durable Power of Attorney for Health
Care (DPAHC), allows for the designation of a spokesperson or surrogate medical
decision maker of the patient's choosing. This surrogate decision maker (often

referred to as a health care agent) makes health care decisions for the patient in the
event she is incapacitated.

Although not actually an advance directive, many states have adopted the use of
life-sustaining treatment order forms to facilitate communication about end-of-life
wishes with regard to the use of treatments. Most prominent and a model for many
states is the POLST, physicians orders for life-sustaining treatment. These orders
stay with the patient and are designed to direct care both in the home and
outpatient settings, and are used sometimes to facilitate transfers within the
hospital.

Although advance directives are usually focused on end-of-life decision making,

there is another type of directive for patients with recurrent severe mental health
problems. This is the mental health directive or psychiatric advance directive. In this
type of directive the patient informs health care providers about their preferences
for future mental health care if s/he were to become decisionally incapacitated.

Why are advance directives important to medical care?

The major ethical argument for the use of instructive directives, such as a living will,
appeals to the ethical principle of autonomy. The principle of autonomy requires
physicians to respect the wishes of competent adult patients. Even after a patient
loses the capacity to be autonomous, we can continue to respect autonomy by
abiding by the patients prior expressed wishes. In this way, patients can continue
to participate (indirectly) in their medical care decisions even if they become
decisionally incapacitated, i.e., unable to make informed decisions. Instructive
directives may extend individual autonomy and help ensure that future care is
consistent with previous desires. The living will was created initially to help prevent
unwanted, invasive medical care at the end of life. However, the living will also
attempts to ensure that patients receive the treatment they want, which may be
invasive, end-of-life care. Most importantly, the living will tries to promote patientcentered care.

When a patient becomes incapacitated someone else will be required to make

health care decisions. In most states, the patients spouse is the legal surrogate.
Domestic partnership laws in some states empower non-spouse, registered
domestic partners to act as surrogate decision makers. If no spouse is available,

state law usually designates the order of surrogate decision makers, usually other
family members. In Washington State the order of hierarchy is codified in
RCW7.70.065. By designating a health care agent through a DPAHC, the patient's
choice of a surrogate decision maker supersedes that of the state. A legal surrogate
is particularly valuable for persons in non-traditional relationships or without close
family. The health care agent need not be a relative of the patient, though this
person should have close knowledge of the patient's wishes and views.

Are advance directives legally binding?

Advance directives are recognized in one form or another by legislative action in all
50 states (in Washington, see RCW 70.122). If the directive is constructed according
to the outlines provided by pertinent state legislation, they can be considered
legally binding. In questionable cases the medical center's attorney or ethics
advisory committee can provide guidance on how to proceed (see also the topics
Law and Ethics and Ethics Committees).

When should I refer to a patient's advance directive?

It is best to ask a patient early in his care if he has a living will or other form of
advance directive. Not only does this information get included in the patient's chart,
but by raising the issue, the patient has an opportunity to clarify his/her wishes with
the care providers and loved ones.

However, advance directives take effect only in situations where a patient is unable
to participate directly in medical decision making. Appeals to living wills and
surrogate decision makers are ethically and legally inappropriate when individuals
remain competent to guide their own care. The assessment of decisional incapacity
may be difficult at times, is thought to be a responsibility of most physicians, but
sometimes may require a psychiatric evaluation.

Some directives are written to apply only in particular clinical situations, such as
when the patient has a "terminal" condition or an "incurable" illness. These
ambiguous terms mean that directives must be interpreted by caregivers. Some
more recent types of instructive directives have attempted to overcome this

ambiguity by addressing specific interventions (e.g. blood transfusions or CPR) that

are to be prohibited in specified clinical contexts.

What if a patient changes her mind?

As long as a patient remains able to participate in medical decisions, both

documents are revocable. Informed decisions by patients with decision-making
capacity always supersede a written directive.

What if the family disagrees with a patient's living will?

If there is a disagreement about either the interpretation or the authority of a

patient's living will, the medical team should meet with the family and clarify what
is at issue. The team should explore the family's rationale for disagreeing with the
living will. Do they have a different idea of what should be done (e.g., based on
other communication from the patient)? Do they have a different impression of what
would be in the patient's best interests, given her values and commitments? Or
does the family disagree with the physician's interpretation of the living will? Is
there a conflict of interest that may be fueling disagreement between the patient
and family members?

These are complex and sensitive situations and a careful dialogue can usually
surface many other fears and concerns. However, if the family merely does not like
what the patient has requested, they do not have much ethical authority to sway
the team. If the disagreement is based on new knowledge, substituted judgment, or
recognition that the medical team has misinterpreted the living will, the family has
much more say in the situation and most hospitals would defer to the family in
these situations. If no agreement is reached, the hospital's Ethics Committee or
Ethics Consultation Service should be consulted.

How should I interpret a patient's advance directive?

Living wills generally are written in ambiguous terms and demand interpretation by
providers. Terms like "extraordinary means" and "unnaturally prolonging my life"

need to be placed in context of the present patient's values in order to be

meaningfully understood. The health care agent or a close family member often can
help the care team reach an understanding about what the patient would have
wanted. Of course, physician-patient dialogue is the best guide for developing a
personalized advance directive.

What are the limitations of living wills?

Living wills cannot cover all conceivable end-of-life decisions. There is too much
variability in clinical decision making to make an all-encompassing living will
possible. Persons who have written or are considering writing advance directives
should be made aware of the fact that these documents are insufficient to ensure
that all decisions regarding care at the end of life will be made in accordance with
their written wishes. Moreover, the language that is often employed in advance
directives is frequently imprecise. What seems clear to the author may seem cloudy
to others when reviewed in a clinical situation. A partial remedy to this limitation is
to strongly encourage patients to communicate preferences and values to both their
medical providers and family/surrogate decision makers, and to encourage them to
identify a health care agent (through a durable power of attorney for health care)
where appropriate.

Another potential limitation of advance directives is possible changes in the

patient's preferences over time or circumstance. People often accommodate to
disabilities and an old living will may become inconsistent with the patient's revised
views about quality of life or other outcomes. This is yet another reason to
recommend ongoing communication between patients and their physicians and
family members.

Policy On Do Not Resuscitate

Resuscitation is a medical procedure which seeks to restore cardiac and/or

respiratory function to individuals who have sustained a cardiac and/or respiratory
arrest. "Do Not Resuscitate" ("DNR") is a medical order to provide no resuscitation
to individuals for whom resuscitation is not warranted.

Cardiopulmonary resuscitation ("CPR") is the common term used to refer to

resuscitation. However, the options available to treat very sick patients are broader
than CPR as literally defined. Other options include intensive care, antibiotic
therapy, hydration, and nutritional support. Appropriate comfort care measures
should be employed for all patients, especially terminally ill patients.

DNR Protocol

DNR orders given at the Cleveland Clinic shall invoke a protocol hereinafter referred
to as the DNR Protocol. The DNR Protocol has been adopted by the Ohio Department
of Health as appropriate for statewide use and requires that emergency care and
other health care providers:

WILL suction the airway, administer oxygen, position for comfort, splint or
immobilize, control bleeding, provide pain medication, provide emotional support,
and contact other appropriate health care providers, and
WILL NOT administer chest compressions, insert an artificial airway, administer
resuscitative drugs, defibrillate or cardiovert, provide respiratory assistance (other
than suctioning the airway and administering oxygen), initiate resuscitative IV, or
initiate cardiac monitoring.
Types of DNR Orders

The diversity of patients, illnesses, and therapies requires that DNR orders be
adaptable to specific circumstances. To ensure flexibility three types of DNR orders
may be given for Cleveland Clinic patients:

DNR Comfort Care

"DNR Comfort Care" orders activate the DNR Protocol at the time the order is given.
DNR Comfort Care orders permit comfort care only both before and during a cardiac
or respiratory arrest. Resuscitative therapies will not be administered prior to an
arrest. This order is generally regarded as appropriate for patients who have a
terminal illness, short life expectancy, little chance of surviving CPR, and a desire to
let nature take its course in the face of an impending arrest. DNR Comfort Care
orders can be made portable and be given effect outside the Cleveland Clinic if the
procedures set forth below are followed (see Ohio Portability Rules).

DNR Comfort Care-Arrest

"DNR Comfort Care-Arrest" orders activate the DNR Protocol at the time of a cardiac
or respiratory arrest. A cardiac arrest occurs when there is an absence of a palpable
pulse. A respiratory arrest occurs when there are no spontaneous respirations or
there is agonal breathing. Resuscitative therapies will be administered before an
arrest but not during an arrest. The term "DNR" (without additional wording) when
recorded in the medical chart shall be considered a "DNR Comfort Care-Arrest"
order. DNR Comfort Care-Arrest orders can be made portable and be given effect
outside the Cleveland Clinic if the procedures set forth below are followed (see Ohio
Portability Rules).

DNR Specified
All other DNR orders are "DNR Specified" orders. DNR Specified orders modify the
DNR Protocol in some respect, either in treatment modalities or in the timing of the
protocol activation. DNR Specified orders cannot be made portable and given effect
outside the Cleveland Clinic.

Authority to Give a DNR Order

Although any physician and certain nurse practitioners legally may give DNR orders
in Ohio, at the Cleveland Clinic only a patient's primary physician may give a DNR
order. The primary physician is generally the first physician listed on the patient's
data card. Primary physicians may delegate to physician residents the authority to
record a DNR order in the medical chart.

Patient Consent to a DNR Order

DNR is a medical order to be given only by authorized health care practitioners.

DNR orders generally should be given with the informed consent of the patient or
the patient I s surrogate decision-maker. Ideally, the physician should sensitively
discuss the DNR option with the patient while the patient is mentally competent.
However, DNR orders are often considered for patients who are comatose or who
otherwise lack decisional capacity with whom this discussion has not occurred or
cannot occur. In cases when a patient lacks decisional capacity, the DNR option

should be considered in conjunction with the patient's advance directives, if known,

or should be discussed with a surrogate. A surrogate may be designated by a
patient as the attorney-in-fact in a Durable Power of Attorney for Health Care. A
surrogate may also be identified as the first available person(s) from the following
list, in order: legal guardian, spouse, majority of adult children, parents, majority of
adult siblings, or other nearest adult relative. In all cases the primary physician
should discuss the DNR option with the patient if possible and the surrogate(s) if
appropriate. There is no obligation to offer or initiate CPR if resuscitation would be
futile, i.e., if resuscitation would not achieve its physiological objective, would offer
no benefit to the patient, and would violate reasonable medical standards.

Recording the DNR Order in the Medical Chart

The words "DNR Comfort Care," "DNR Comfort Care-Arrest," 'or "DNR Specified"
should be recorded on the "left-hand side" of the medical chart (where advance
directives are maintained) along with the date, time, rationale for the DNR order,
the names of the patient and/or family members involved in the decision, and a
statement that the patient and/or surrogate was fully informed about and consented
to the DNR order. If a DNR Specified order is recorded, the modifications to the DNR
Protocol should be specified in the medical chart, as well as the desired timing of
the activation of the modified Protocol.

DNR decisions for inpatients should be transmitted clearly to those caring for the
patients. A DNR order should never result in the abandonment of a patient, and
steps should be taken to assure that abandonment is not perceived.

Cleveland Clinic DNR Identification Bracelet

All Cleveland Clinic inpatients for whom a DNR order has been given will wear a
Cleveland Clinic DNR identification wrist bracelet. Such identification is intended to
facilitate communication and direct care to comply with DNR orders previously
given, especially in emergencies. Cleveland Clinic DNR identification bracelets will
be uniform in color and style. They will contain the inpatient's name, Cleveland
Clinic patient history number, and the preprinted designations of the three types of
DNR orders. The type of DNR order given for a particular inpatient will be
holepunched through that patient's bracelet. All Cleveland Clinic inpatients who
have a DNR order will wear a Cleveland Clinic DNR identification wrist bracelet

regardless of whether they are also wearing a state-approved DNR bracelet (see
Ohio Portability Rules below).

Cleveland Clinic DNR Informational Pamphlet

An informational pamphlet which explains Cleveland Clinic's policy and Ohio law
regarding DNR orders will be available to all Cleveland Clinic inpatients and
outpatients who have a DNR order. The pamphlet will include explanations of the
types of DNR orders at the Cleveland Clinic, the use of the Cleveland Clinic DNR
bracelet, the status of DNR during invasive procedures, the manner in which DNR
orders may be revoked, and Ohio's DNR portability regulations. The pamphlet will
encourage patients and family members to ask their physicians any questions they
may have about DNR.

Reassessment and Revocation of DNR Orders

The DNR order should be reassessed as part of the ongoing evaluation of an

inpatient. A DNR order should be affirmed, modified, or revoked only after a
discussion between the primary physician and the patient, if possible, or the
surrogate(s) if appropriate, and the consent of the patient or surrogate. DNR orders
should be reassessed frequently and as conditions warrant. Reassessments of DNR
orders should be documented in the medical chart. If a DNR order is changed from
one of the three types of DNR orders to a different type, the patient's Cleveland
Clinic DNR bracelet should be replaced with a new bracelet containing the revised
designation. If a DNR order is revoked, the Cleveland Clinic DNR bracelet should be
removed and destroyed. A physician or other health care worker who feels that he
or she cannot honor a patient's DNR request may not prevent or delay the transfer
of the patient to a physician or facility which will honor the DNR status.

Invasive Procedures and Anesthesia Care

The administration of anesthesia necessarily involves some practices and

procedures that might be viewed as resuscitation in other settings. Prior to any
inpatient or outpatient invasive procedure for which Cleveland Clinic policy requires
the documentation of informed consent, any existing DNR order should, when
possible, be reviewed with the patient or the patient's surrogate. As a result of this

review, the status of the DNR order during the perioperative period should be
affirmed, clarified, or modified based on the preferences of the patient. Any
clarifications or modifications should be documented in the medical chart along with
a notation indicating if or when the original DNR order should be reinstated.
Concurrence on these issues by the primary physician, the surgeon, and the
anesthesiologist is desirable. The Cleveland Clinic DNR bracelet should not be
removed during the perioperative period, even if the DNR order has been
temporarily modified.

Conflicts Between DNR Orders and Advance Directives

In the event of a conflict between one of the three types of DNR orders and an
advance directive which has become effective because a person is unable to
communicate and is terminally ill or permanently unconscious, the instructions from
the document (or person named as an Attorney-in-Fact) ranked higher in the
following list shall prevail:

Living will of a person who is in a terminal condition or a permanent unconscious

state.
Durable Power of Attorney for Health Care, or an Attorney-in-Fact acting in
accordance therewith, of a person who is in a terminal condition or a permanent
unconscious state.
DNR order.
Ohio Portability Rules

The three types of DNR orders are for use within the Cleveland Clinic and probably
would not be honored outside the Cleveland Clinic. However, some patients wish to
have DNR orders travel with them, or be "portable." "DNR Comfort Care" and "DNR
Comfort Care-Arrest" orders may be made portable and should be honored
statewide by EMS and other emergency care workers outside the Cleveland Clinic if
the following procedures are followed by the primary physicians giving the DNR
orders. Note: "DNR Specified" orders cannot be made portable.

Patients should be provided with one of the following state-approved forms of DNR
identification: (1) a DNR identification form, (2) a transparent hospital-type bracelet

with an insert, (3) a wallet card, or (4) a prescription for either a bracelet or
necklace manufactured pursuant to specifications of the Ohio Department of Health.
All of these forms, which are available at the Cleveland Clinic, contain at least the
patient's name and the state-approved DNR Comfort Care logo depicted below.
Copies of any state-approved forms of DNR identification should be inserted on the
"left-hand side" of the medical chart (where advance directives are maintained).
Cleveland Clinic inpatients who have state-approved DNR identification (including
bracelets) also will wear Cleveland Clinic DNR identification bracelets.

(Insert State-Approved DNR Comfort Care Logo)

Patients who request state-approved DNR identification should be given a Cleveland
Clinic DNR Informational Pamphlet and be fully informed about the effect of their
DNR orders and how emergency medical services personnel will respond to their
type of DNR order. The type of DNR order, the medical reasons for the DNR order,
and a statement that the patient or surrogate was fully informed about and
consented to the DNR order should be recorded in the medical chart.

What is a Do Not Resuscitate (DNR) Order?

A DNR order is a medical order issued by a physician or other authorized

practitioner that directs healthcare providers not to administer CPR (Cardio
Pulmonary Resuscitation) in the event of cardiac or respiratory arrest. A DNR order
may be written in the absence of a living will or the conditions that would make a
living will operative. A living will may contain a provision indicating that a patient
does not desire CPR. However, if a patients preference to forgo CPR is expressed
only in a living will, CPR will be withheld only when a physician has determined that
the patient is not competent and has certified in writing that the patient has an endstage medical condition or is permanently unconscious.1 Without such physician
determination and certification or without a DNR order, the patients expressed
preference for withholding CPR is not sufficient.2 In order for a patients preferences
to be carried out, patients, families, and healthcare providers must understand the
distinction between the circumstances under which a living will and a DNR order are
applicable.
A DNR order is not subject to the preconditions imposed by the Living Will Act. A
DNR order becomes operative only in the narrow context of cardiac or respiratory
arrest regardless of the precipitating clinical event and does not preclude otherwise
appropriate treatments or life-sustaining interventions.2,7 Misinterpretation of DNR
orders was demonstrated by a survey conducted in an outpatient cancer center,

which showed that only 34% of the patients correctly understood the meaning of a
DNR order; 66% of the patients did not realize that a DNR order would result in not
being resuscitated even if the cause of the cardiac or respiratory arrest was
potentially reversible.8
In June of 2002 Pennsylvania enacted the Do-Not-Resuscitate Act (DNR Act) (P.L.
409, No. 59) (20 Pa.C.S. 54A01-54A13). The DNR Act empowered a terminally ill
person or the persons surrogate to secure an out-of-hospital do-not-resuscitate
order and, at the persons option or the option of an authorized representative, an
out-of-hospital DNR bracelet or necklace. These items direct emergency medical
services (EMS) personnel in the out-of-hospital setting not to provide the person for
whom they are issued with cardiopulmonary resuscitation in the event of the
persons cardiac or respiratory arrest. The DNR Act also specified the circumstances
under which an appropriate representative of a person who issued a declaration
under the Advance Declaration for Health Care Act (former Living Will Act) would be
able to secure an out-of-hospital DNR order, bracelet or necklace for the person if
the person became permanently unconscious. These provisions, supplemented by
Department of Health regulations (28 Pa. Code 1051.1-1051.101), went into
effect March 1, 2003, and were amended February 7, 2004.

Specifically, an out-of-hospital DNR order is a written order that is issued by a

persons attending physician that directs EMS providers to withhold CPR from the
person in the event of that persons cardiac or respiratory arrest. Thus, if an
ambulance is called to attend to a person for whom an out-of-hospital DNR order
has been issued and the ambulance crew observes the out-of-hospital DNR order
with original signatures with the person, or observes that the person is wearing an
out-of-hospital DNR bracelet or necklace, the ambulance crew will not attempt CPR
unless it is appropriately communicated to a member of the crew that the out-ofhospital DNR order has been revoked.

Definitions:
1.
Cardio-Pulmonary Resuscitation (CPR): refers to the medical procedures used
to restart a persons heart and breathing when the person suffers cardiac or
respiratory arrest. CPR may involve simple efforts such as mouth-to-mouth
resuscitation and external chest compression. Advanced CPR may involve insertion
of a tube to open the persons airway or to assist breathing, injection of
medications, or providing an electrical shock (defibrillation) to resuscitate the heart.
2.
End-Stage Medical Condition: An end-stage medical condition is an
incurable and irreversible medical condition in an advanced state caused by injury,
disease, or physical illness that will, in the opinion of the attending physician, to a

reasonable degree of medical certainty, result in death, despite the introduction or

continuation of medical treatment. If a patient having an end-stage medical
condition serves as the reason for which an out-of-hospital DNR order is sought for
that patient, the attending physician must make the determination that the patient
has an end-stage medical condition before the physician may issue an out-ofhospital DNR order for the patient. All persons who are in a terminal condition have
an end-stage medical condition.
3.
Permanently Unconscious: Permanently unconscious is a medical condition
that has been diagnosed in accordance with currently accepted medical standards
and with reasonable medical certainty as total and irreversible loss of consciousness
and capacity for interaction with the environment. The term includes, without
limitation, a persistent vegetative state or irreversible coma. If a patient being
permanently unconscious serves as the reason for which an out-of-hospital DNR
order is sought for the patient, the attending physician must make the
determination that the patient is permanently unconscious and the patient must
have previously executed a living will which provides that no CPR be administered in
the event of the persons cardiac or respiratory arrest if the person becomes
permanently unconscious, or authorizes a surrogate or other authorized
representative of the person to make that decision under those circumstances.
4.
Emergency Medical Services (EMS) Provider: EMS providers are individuals
licensed, certified, recognized, or otherwise authorized under the Emergency
Medical Services Act (35 P.S. 6921-6934) to provide medical care on an
emergency, out-of-hospital basis. They are most frequently associated with
ambulance services. EMS personnel who administer emergency treatment include
EMTs (emergency medical technicians), EMT-paramedics (paramedics), prehospital
registered nurses, ambulance attendants, first responders and health professional
physicians. EMS providers also include individuals given good Samaritan civil
immunity protection under Pennsylvania law (42 Pa.C.S. 8331.2) when using an
automated external defibrillator. Physicians who provide medical command to EMS
personnel must also honor an out-of-hospital DNR order when appraised of it by
EMS personnel.
5.
Attending Physician: An attending physician is a physician who has primary
responsibility for the treatment and care of the person. More than one physician
may have primary responsibility for the medical care and treatment of a person. A
physician who is requested to issue an out-of-hospital DNR order for a person needs
to make a good faith judgment as to whether the physician is an attending
physician of the person based upon the medical care the physician provides to the
person. If the physician determines that the circumstances of the physician-patient
relationship do not enable the physician to determine whether he or she qualifies as
the patients attending physician, the physician will attempt to supplement that
knowledge with information the physician secures after making reasonable inquiries

of the person or the persons surrogate or other authorized representative regarding

the medical care the person is receiving from other physicians.
6.
Surrogate: For purposes of the repealed DNR Act and the regulations that
were adopted pursuant to that act, a surrogate is an individual who has, or
individuals who collectively have, legal authority to request an out-of-hospital DNR
order for another person or to revoke that order. Under the Act the term surrogate
is limited to a health care agent or health care representative as those terms are
defined in the Health Care Agents and Representatives Act (20 Pa.C.S. 54515465). This does not include all persons who fall under the former definition of
surrogate. However, the Act permits persons other than surrogates, by virtue of
their special relationship to the person for whom an out-of hospital DNR order is
sought, to also make a request for an out-of-hospital DNR order for that person. An
example of such a person is a parent of a child who has an end-stage medical
condition who is under 18 years of age and who is not emancipated, who has not
graduated high school or been married, and who does not have a court-appointed
guardian. Yet another example is a court-appointed guardian for an adult who has
an end-stage medical condition and who the court concludes is unable to meet
essential requirements for his or her physical health or safety because the person
does not have the ability to receive and evaluate relevant information effectively or
communicate relevant decisions. However, other than when a person is relying
upon the definition of surrogate in the Act to qualify to ask for an out-of-hospital
DNR order for another person, the focus should be on whether that person, by virtue
of a special relationship to the person for whom the out-of-hospital DNR order is
sought, has legal authority to request an out-of-hospital DNR order for that person.
We encourage you to seek the advice of an attorney if you have a question
regarding who can serve as a surrogate or other authorized representative for
another person to request an out-of-hospital DNR order for that person.