Everything about Do Not Resuscitate totally explained
A
Do Not Resuscitate, or
DNR order is a written order from a
doctor that
resuscitation shouldn't be attempted if a person suffers
cardiac or
respiratory arrest. Such an order may be instituted on the basis of an
advance directive from a person, or from someone entitled to make decisions on their behalf, such as a
health care proxy; in some jurisdictions, such orders can also be instituted on the basis of a physician's own initiative, usually when resuscitation wouldn't alter the ultimate outcome of a disease, and is designed to prevent unnecessary suffering.
Any person who doesn't wish to undergo
lifesaving treatment in the event of cardiac or respiratory arrest can get a DNR order, although DNR is more commonly done when a person who has an
inevitably fatal illness wishes to have a more natural
death without painful or invasive medical procedures.
A common belief is that most attempts at cardiopulmonary resuscitation (CPR) are successful. In contrast to
medical dramas seen on TV, cardiopulmonary resuscitation has a success rate of surviving to discharge from the hospital around 10-20 percent. Of those who do survive initial resuscitation, a large proportion either die shortly afterward or are left with permanent physical/neurological deficiencies. Therefore, medical students and doctors alike are encouraged to be realistic with patients and families when discussing DNR orders, as it's thought that many wrongly believe resuscitation to be a risk-free guarantee to life.
Alternate Names
Alternate namings and abbreviations for this order are used depending on the geographic region.
DNR (Do Not Resuscitate) is a common abbreviation in the United States and the United Kingdom. It may be clarified in some regions with the addition of
DNI (Do Not Intubate), although in some hospitals
DNR alone will imply no
intubation. Some areas of the United States and the United Kingdom include the letter A, as in
DNAR, to clarify "Do Not
Attempt Resuscitation." This alteration is so that it isn't presumed by the patient/family that an attempt at resuscitation will be successful. Since the term DNR implies the omission of action, and therefore 'giving up', some have advocated for these orders to be re-termed
Allow Natural Death. However the acronym
AND could obviously be confused with the conjunction 'and' so this hasn't been popular in hospitals. New Zealand and Australia (and some hospitals in the UK) use the term
NFR or
Not For Resuscitation. Typically these abbreviations are written without periods in between the letters, for example
DNR not
D.N.R.
Until recently in the UK it was common to write "Not for 222" or conversationally, "Not for twos." This was implicitly a hospital DNR order, where 222 (or similar) is the hospital telephone number for the emergency resuscitation or crash team.
United States
The DNR order came into being in the
U.S. in the 1960s when
defibrillation allowed the reversal of cardiac arrest, but this may prolong the life of the patient for only a short time.
In the U.S.,
cardiopulmonary resuscitation (CPR) and
advanced cardiac life support (ACLS) shouldn't be performed if a valid written "DNR" order is present. In any cases of doubt,
emergency medical technicians,
paramedics and other
medical workers will perform as if a DNR order didn't exist, as is required by law.
For the DNR to be valid there may be rules such as the use of a special form and/or additional signatures of a doctor and/or witnesses, etc. The exact rules for obtaining a DNR order, and for emergency medical personnel to accept the validity of one, vary widely according to jurisdiction. For example, in the state of
Maryland, only state DNR orders are acceptable, and they require much verification, witnesses and doctor's signatures in order to be valid. In contrast, the state of
Virginia allows patients to receive a DNR order with relative ease, and will accept them from most jurisdictions.
In many jurisdictions, medical professionals are ordered not to acknowledge DNR orders. This is especially common with
paramedics, who are often employed by private companies unwilling to fight a potential lawsuit.
A DNR order must be filed on a jurisdictionally recognized form. A doctor contemplating a DNR decision should make every reasonable effort to confirm a DNR status before deciding to withhold resuscitation. To be sure that their DNR request is honored, patients should make their wishes clearly known to their family, doctors, community hospitals, care homes and any other caregivers or health care providers who may be present should a cardiac arrest occur. Some jurisdictions provide for a legally sanctioned DNR notification that's clearly visible to all healthcare personnel, similar to a
MedicAlert bracelet.
A DNR order's specific effect depends on the hospital in which the incident occurs and the terms laid out in the DNR: neither cardiopulmonary resuscitation nor
intubation will be performed, but treatment for infections or other treatable conditions, intravenous feeding and fluids, pain management and comfort care are generally continued.
Further Information
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