DNR (Do-not-resuscitate) order


Dr.Ashok Hande

6/25/20234 min read

A do-not-resuscitate order, or DNR order, is a medical order written by a doctor. It instructs healthcare providers not to do cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating.

Ideally, a DNR order is created, or set up, before an emergency occurs. A DNR order allows you to choose whether or not you want CPR in an emergency. It is specific about CPR. It does not have instructions for other treatments, such as pain medicine, other medicines, or nutrition.

  • The doctor writes the order only after talking about it with the patient (if possible), the proxy, or the patient's family.

  • If you are near the end of your life or you have an illness that will not improve, you can choose whether you want CPR to be done. If you do want to receive CPR, you do not have to do anything.

  • If you do not want CPR, talk with your doctor about a DNR order.

  • These can be hard choices for you and those who are close to you. There is no hard and fast rule about what you may choose.

  • Think about the issue while you are still able to decide for yourself.

  • Learn more about your medical condition and what to expect in the future.

  • Talk to your doctor about the pros and cons of CPR.

  • A DNR order may be a part of a hospice care plan. The focus of this care is not to prolong life, but to treat symptoms of pain or shortness of breath, and to maintain comfort.

  • If you have a DNR order, you always have the right to change your mind and request CPR.

How is a DNR Order Created?

  1. If you decide you want a DNR order, tell your doctor and healthcare team what you want. Your doctor must follow your wishes.

  2. If you are a patient in a hospital or nursing home, your doctor must agree to settle any disputes so that your wishes are followed.

  3. The doctor can fill out the form for the DNR order.

  4. The doctor writes the DNR order in your medical record if you are in the hospital.

  5. Inform your health care agent (also called health care proxy) and family of your decision

  6. If you do change your mind, talk with your doctor or healthcare team right away. Also, tell your family and caregivers about your decision.

  7. When You are Unable to Make the Decision

  8. Due to illness or injury, you may not be able to state your wishes about CPR. In this case:

  9. If your doctor has already written a DNR order at your request, your family may not override it.

  10. You may have named someone to speak for you, such as a healthcare agent. If so, this person or a legal guardian can agree to a DNR order for you.

  11. If you have not named someone to speak for you, under some circumstances, a family member can agree to a DNR order for you, but only when you are not able to make your own medical decisions.

A do-not-resuscitate order (DNR), also known as Do Not Attempt Resuscitation (DNAR), Do Not Attempt Cardiopulmonary Resuscitation, is a legal order, written or oral depending on the country, indicating that a person should not receive cardiopulmonary resuscitation (CPR) if that person's heart stops beating. Cardiopulmonary resuscitation (CPR) is widely practiced by healthcare professionals to revive the heartbeat and breathing in a patient suffering from cardiac/ respiratory arrest. It is increasingly being recognized that in some patients with specific medical conditions, CPR does not alter the overall outcome of illness, and is likely to increase suffering and further deteriorate the quality of life. Do Not Attempt Resuscitation (DNAR) as an option has been practiced in many countries for such cases to avoid futile CPR and maintain the dignity of the patient. The decision of DNAR should be taken by the treating physician who is well versed with the patient's medical condition, with information to the patient or her/his surrogate. While ordering DNAR on the patient's medical case record, every effort should be made to treat the underlying disease and continue optimal medical care with compassion.

DNR would apply to a patient with a progressive debilitating/incurable/terminal illness where CPR would be inappropriate, non-beneficial, and likely to prolong the suffering of the patient in the best judgment of the treating physician(s). While applying this principle, compassionate care is integral to the overall goals of medical treatment. DNR is distinct from withdrawal or withholding of other life-supporting treatments. Sometimes these decisions and the relevant documents also encompass decisions around other critical or life-prolonging medical interventions. The legal status and processes surrounding DNR orders vary from country to country. Most commonly, the order is placed by a physician based on a combination of medical judgment and patient wishes and values.[4]

A DNR order does not mean "do not treat." Rather, it means only that CPR will not be attempted. Other treatments (for example, antibiotic therapy, transfusions, dialysis, or the use of a ventilator) that may prolong life can still be provided. Depending on the person's condition, these other treatments are usually more likely to be successful than CPR. Treatment that keeps the person free of pain and comfortable (called palliative care) should always be given.

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.

The guidelines suggest that decisions typically be made in hospital admissions, where death is imminent in hours or days, in advanced incurable disease. The guidelines emphasize that DNA-R decisions are not advance directives.

Advance directives, first permitted by the Supreme Court of India in 2018, support the right to die with dignity. They allow patients to make legally binding decisions to withdraw treatment should they enter a vegetative state or develop a terminal illness. However, the mandated process is quite cumbersome. Patients must sign an advance directive with two witnesses and a magistrate. When patients fall ill and are admitted to the hospital, a hospital board with four senior clinicians needs to draft a preliminary report to be forwarded to the district collector, who will then arrange for another four-doctor medical panel, including the chief district medical officer. The panel then advises a magistrate, who will visit the hospital to finally instruct treatment withdrawal.

Decisions should be individualized and must respect patient autonomy.