Do
Not Resuscitate (DNR) Orders
During
the course of your practice you will come across patients who
have a "Do Not Resuscitate" order on their
chart. A do-not-resuscitate (DNR) order, (sometimes
referred to as "no code order"), allows people to
declare that they do not want certain resuscitative measures
performed on them. It specifically tells medical professionals
not to perform certain life saving or sustaining measures such
as CPR, advanced airway management, defibrillation, artificial
ventilations and transcutaneous cardiac pacing.
This
means that doctors, nurses and emergency medical personnel will
not attempt emergency CPR if the patient's breathing or
heartbeat stops as long as a valid DNR Order has been completed
for the patient and is on record. DNR orders may be written for
patients in a hospital or nursing home, or for patients at home.
Hospital DNR orders tell the medical staff not to revive the
patient if cardiac arrest occurs. If the patient is in a nursing
home or at home, a DNR order tells the staff and emergency
medical personnel not to perform emergency resuscitation and not
to transfer the patient to a hospital for CPR.
Key
Points
-
Patient
has the right to refuse resuscitative efforts. They also
have the right to revoke the DNR at any time
-
DNR
requires specific written orders from physician.
-
Resuscitation
efforts should be begun when in doubt or when written orders
are not present.
-
A
patient does not need to have a living will before a DNR
order can be entered, although having a living will may
simplify the process of obtaining a DNR order.
-
While
a DNR order on a chart is acceptable in a hospital, it's not
appropriate for use by EMS providers. Check your state's
prehospital DNR statutes.
Questions and Answers About DNR Orders:
What is the purpose of this form?
This law supplements documents and policies used in hospitals, nursing homes
and hospices. In some cases, people who are terminally ill choose to live out
the remainder of their lives at home. When a person dies, a family member
often calls an ambulance service, and emergency personnel are required by
law to attempt resuscitation. This law allows individuals to avoid
unnecessary resuscitation attempts.
Where should I keep the form?
The law requires the individual signing the Do Not Resuscitate Order to keep
the document accessible and in his or her possession. As an alternative, a
person may wear a bracelet alerting emergency personnel to the Do Not Resuscitate
Order. If you choose to wear a med alert bracelet, the bracelet must include your
name and address, and the name and telephone number of your attending
physician.
Who must sign the form?
A competent adult or the legally appointed advocate of an incompetent adult
must sign the form. In either case, the person must be 18 years of age or older
and be of sound mind. The document also must be signed by the individual's
attending physician and two witnesses. If you have religious or other objections to
care by a physician you can create a document that does not require a physician's
signature By law, your family, physicians and employees of your health care facility
are not allowed to be witnesses for this form.
What if I am unable to sign this form?
If you are an incompetent adult and have an advocate, your advocate may
execute a Do Not Resuscitate Order on your behalf. You must have, in an
advance directive, authorized your patient advocate to refuse treatment that
could allow you to die.
Can I change my mind once I sign the form?
Yes. You can change the document at any time while you are competent.
What else should I do to ensure my wishes are carried out?
Make your wishes known by talking with your family, friends or doctor, and
alert them to the Do Not Resuscitate Order you have signed - and where they
can find it.
Reading
Suggestions
Selected
Reviewed Sites and Resources
This
list of resources is highly selective and does not include every
web site related to these topics. If you would like to add a
resource click here.
- Printable
hand out for patients and families that explain Advanced
Directives, Living Wills, Power of Attorney, and DNR Orders.
[American Academy of Family Physicians].
Do-Not-Resuscitate
Orders - Comprehensive
questions and answers about DNR Orders, cases when CPR should
or shouldn't be administered, and the ethical issues involved
in DNR decision making for medical professionals as well as
families. Includes three case studies. [Ethics in Medicine,
University of Washington School of Medicine].
DNR
Orders For Medically Fragile Children- Since
there are many severely disabled children in school, some
school districts have had to deal with requests from parents
to not resuscitate their child if death appears imminent This
article raises the question "are DNR orders only
applicable to hospitals and health care facilities or do they
apply to schools and school nurses".
DNR
Case Study: Retarded Patient -The
New York Supreme Court had to decide what to do about a Do Not
Resuscitate order which a physician had written for a 67
year old individual, who was profoundly retarded and had been
institutionalized since the age of five.
Nursing
Care of the DNR Patient- A Comparison of the
Behavioral Intentions of Nurses Working in ICU and Oncology
Units in the Rural Midwest for Older Patients and those with
DNR Orders. [M. Bennett 1991]
Participation
In The Decision To Write A 'Do Not Resuscitate' Order -
Studies
show that nursing staff participates in framing the decision
for DNR orders in more than 56% of all cases. The graphs of
potential participants in framing a 'DNR' order might surprise
you.
Perioperative
Care of Patients With DNR Orders- Nurses have a
responsibility to uphold the rights of patients. A patient
with a do-not-resuscitate (DNR) order may require surgical
procedures and anesthesia management. This position statement
and guidelines from the AORN addresses these issues.
Prehospital
DNR Orders -Paramedics
and other emergency responders working outside the hospital
generally have a duty to provide CPR and other forms of
resuscitation when needed. But some people may not want to be
revived. Over half of the states now have
"prehospital" DNR programs so that a doctor's
DNR order can be honored outside of the hospital setting.
[Legal Information Network]
Statement
on Advance Directives by Patients: "Do Not
Resuscitate" in the Operating Room -(DNR)
orders and requests, are being used with increasing frequency
and may, at times, complicate the operative consent process.
This position statement by the American College of Surgeons
discusses and clarifies the issues involved.
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Remember
whenever discussing legal issues in nursing it is
imperative to review your state's Nurse
Practice Act.
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