What is a Do Not Resuscitate Order
A Do Not Resuscitate (DNR) is a type of advanced directive or medical directive that must be signed by a physician and determines what happens to the patient in the event of an emergency. A DNR is often one of the most difficult decisions people have to make about their own healthcare or that of a loved one. It is oftentimes difficult because people don't fully understand all the principles behind it. So what does it mean to be a DNR?
How Does a DNR Alter Your Care?
Being a DNR doesn't really alter the medical care you receive. You will still be treated the same way. All this means is that if your body dies (you stop breathing, or our heart stops beating) the medical team doesn't try to bring you back to life. In fact many people don't realize that you can be a DNR and still be treated very aggressively in the ICU. Becoming a DNR doesn't mean that medicine is giving up on you. When doctors and nurses stop focusing on treatment and begin to focus on comfort measures only is something called Palliative Care. A DNR order should not be confused with Palliative Care.
What Happens When You Die in the Hospital?
One of the main reasons people sign DNR orders is because of what happens when the hospital staff tries to bring you back to life. This situation is generally referred to as a "code." It is sometimes given different pseudonyms in different hospitals. When the staff codes a patient an entire resuscitation team swarms the room. The chest is forcefully compressed by hand to simulate a heartbeat and circulate blood. A tube is inserted into the mouth and down the throat and you are put on a ventilator to breath for you. If your heart is in a lethal rhythm you are shocked with major amounts of electricity to jolt it back into rhythm. Drugs are administered and manually pumped through the system with chest compressions. If all of this is successful, your heart starts to beat on its own again and the patient ends up on the ventilator to keep him/her breathing. This doesn't usually come without consequences.
Consequences of Being Resuscitated
One of the main potential consequences of being resuscitated is the damage that occurs from the oxygen deprivation to the organs of the body. Even though chest compressions are being done to circulate blood through the body, it still isn't as effective as the regular heartbeat. Also, depending on the nature of the code, even though oxygen is being pumped into the lungs mechanically, the disease itself can prevent some of the oxygen from reaching the blood stream. The longer a code lasts, the greater the chance of damage to the organs. This can be anything from brain damage, to kidney damage, to liver, or lung damage. Anything can be damaged related to lack of oxygenation.
The drugs that are pumped into the body can also contribute to organ damage. These drugs are designed with one organ in mind and that is the heart. These drugs try to restart the heart and get it back in rhythm and raise blood pressure. Sometimes other organs can take damage from these drugs as well.
There is also chance of trauma to the body from chest compressions. It is very normal to hear ribs cracking and cartilage breaking during chest compressions if they are being done right. It takes lots of force to compress the heart with the sternum and ribs sitting over the top of it. Elderly people especially usually receive damage from this. The electrical shock can also be traumatic in and of itself.
So even if you are resuscitated, your chances of recovery and survival can potentially be much lower than they were before the resuscitation. Usually you end up on a ventilator after a code. If you have organs damaged, especially brain damage, there is a chance you may not come off the ventilator. Then your family has major decisions to make regarding your care.
The aftermath of a code is usually the most stressful time for the family. There is a chance that the damage caused by the code can be so great that there is no chance of the patient coming off of the ventilator. In that case the family has to decide on whether to have the patient receive a tracheostomy *(a hole in the neck with a tube in it that allows for permanent mechanical ventilation) or to discontinue life support altogether because that is what the family believes the patient would want. These are very hard decisions to make.
To DNR or Not to DNR
I am neither for nor against a DNR order. In some situations a DNR is warranted and in some it isn't. Some physicians tend to jump to the DNR prematurely and some never bring it up subjecting the patient to many unnecessary hardships. It is ultimately the patient's decision, or in the case of the patient's inability to speak for him/herself, the family's decision. Here are some things to consider.
- Because some physicians prematurely push the DNR status, and some never bring it up you should always ask the opinion of all of your doctors concerning DNR status. Get a consensus from all your doctors and not just one.
- You must take into account if the patient's medical condition is curable. There is a large chance that your condition after the code will be worse than before. If your condition is curable then it may be worth the code. If your condition is incurable, it may not be worth it. Your religious beliefs may also play an important role in your belief in a cure or healing.
- Age is a consideration. The older a person is, the greater the chance of suffering major damage from a code.
- The patient's wishes. Often times I see elderly patients who sign DNR orders when they were in a perfectly normal healthy state simply because they are at peace with the death process, their spiritual beliefs are solid, and they have led good lives that they are happy for. It is unfortunate in some of these cases that when those patients die, their family members override the DNR decision and demand that the staff code the patient because they are clinging so hard to not losing them. There was one occasion where I saw a DNR patient revived, spent weeks recovering and getting off a ventilator in the ICU only to find out what happened. She became extremely angry with her daughter for overriding the DNR because she was ready to pass on.
In closing, I will say that this is one of the most controversial and difficult decisions to make in all of healthcare. If it is possible, I would urge that all patients try to make this decision as early as possible about their status and wishes and be sure to convey them and reach agreement by family members.. This will avoid any last minute decisions that can often times lead to family members feeling like they made a hasty decision or wish they had talked more about it. If after following this advice you still can't reach a decision it is always okay to bring in a health advocate or counselor to help you in the decision making process.
Good Luck and Stay Well!
Harry Watson from Indianapolis, Indiana on November 25, 2010:
Doc J, Great hub. Your writing is really clear and succinct. I'm a retired paramedic, back in school for nursing. I had some input at the state level on DNR standardization in Indiana. I'm working on a hub about hospice care. I'm hoping my death is sudden and painless at a very advanced age. It must be cool to work in Memphis. I would love to work at St Jude if they are as good as their image would imply.
Jacqui on October 05, 2010:
I am a fairly healthy 35 year old. I found this interesting as i would like a DNR, to take away exactly what it states about the decision being put onto my family.
I am totally at peace with the death process and believe what will be will be.
I would not like to go through any kind of resuscitation. Some people may argue the fact that i don't value my life, they are entitled to their opinion. It is my personal decision for whatever reason, and of sound body and mind wish to have.