DNR (Do-Not-Resuscitate): An Overview
Ethical and legal aspects of declaring DNR
Author: Dr. Riaz Ahmed, Consultant Paediatric Neurologist
DNR stands for "Do Not Resuscitate." A person who does not wish to have cardiopulmonary resuscitation (CPR) performed may make this wish known through a doctor's order called a DNR order. The DNR request is usually made by the patient or health care power of attorney and allows the medical teams taking care of them to respect their wishes.
Physicians often come across a situation in their clinical practice of writing an ethical code of DNR to the critically ill patient where there is limited chance of survival and/or acceptable quality of life(QoL). In other words, it is a legal order written on a legal form to withhold cardiopulmonary resuscitation (CPR) or advanced cardiac life support (ACLS), in respect of the wishes of a patient in case their heart and/or breathing were to stop. Healthcare workers use different terminologies namely allow natural death (AND) or no code as against calling code or ‘Code Blue’, where active resuscitation team is alerted for all life saving measures in a hospital setup.
The most important thing to remember and reiterate that the verdict DNR does not affect other treatment modalities other than that which would require invasive intubation and CPR. In many situations the code DNR is misinterpreted by some healthcare workers which result in ignoring such patients for their basic needs namely physical therapy, nutrition and even sometimes treatments. I should say that it is a total mistake and ignorance by the staff taking care of them and by all means every comfort and basic needs need to be fulfilled for them. There were situations I had encountered negativism from those who deny such requirements from them because of the “no code” legal form attached to their medical records and we have to personally persuade them to do the best possible. So referrals to those ancillary medical care faculties must be informed about the need for management in advance.
A sample DNR
Yet other situation that junior doctors face in the emergency room (ER) when such DNR patients arrive from home with life threatening cardio-respiratory compromise; whether to activate “code” or not as most of the team in ER is different from the treating physicians’ and no information or medical records would be available at that point of time of arrival of such patients. Since DNR is not proclaimed openly and neither the patient /the relatives carry any label or card nor any information is given in the discharge summary, decision making, at the time of critical events would pose a major problem in medical decisions. In such events, very often, “code” is activated and all resuscitative life-saving measures undertaken till the file of the patient arrives in order to alleviate the care-takers’ anxiety and in the bargain many times the scenario ends up ‘full code”’ including invasive ventilation thus negating the DNR definition.
This problem sometimes crops in the hospital stay of such patients who are labeled DNR but while the actual life threatening situation arises care takers of the patients demand full code.
The real meaning of DNR status loses its credibility sometimes when surgeons revert it to perform surgical procedures under deep anesthesia and sometimes patient goes into a state of un-arousability or failure to extubate after anesthesia. Such patients invariably end up with intensive care unit admission with invasive ventilator support. So in short, not always DNR verdict is a divine status and many diverse events could create ambiguity and thus the real credibility is questioned many times.
A junior physician once asked that why should a patient be DNRed when the real meaning of this phrase really doesn’t exist for ever because of the ambiguity of its importance. While signing the papers by at least 3 consultants, its agreed upon unanimously that the decision is made on medical grounds regarding the status of the patient and poor outcome of the benefit of intensive treatment if any. So a consensus opinion should be put forth and documented in the file with concurrence of the patient and family and secondarily approved by medical administration. This calls for a ethical committee from the medical institute to authorize the decision and certify the order. Religious affairs should be the part of the team to acknowledge the importance and to alleviate the taboos among the relatives of the patient.
A uniform code as red flag has to be in the system of all medical institutes reflecting the DNR status so that the transparency is revealed with no doubts. This could avoid hospital shopping of the patient in terms of crisis and thus alleviate the economical burden to a large extent. Will it happen in practical terms? In many countries, DNR status exists as “doctor’s secrete code” in papers and not acknowledged by patients/relatives or hospital administration in written form and so the threat of demand for full code lingers in critical situations. Extreme cases of patients tattooing on their bodies “Do Not Resuscitate Me” creates confusion about the authenticity of this for decision making.
As a practicing physician and pediatrician such incidents and many more similar events I encountered in the no code situations of the patients and with careful tactics as well experience, I managed to solve the issue but at not always in every patient. Enough and adequate knowledge as well experience is needed in order to understand the real meaning of DNR and there should not arise any ambiguity among the treating and supporting physician regarding the decision. Careful explanation of the situation and consequences must have been explained in details by the experienced and senior physician to the patient and relatives. So DNR declaration is neither a death verdict nor a loose and changeable statement on a patient’s medical decision and the real meaning needs to be understand and acknowledged properly.