How to Establish a Do Not Resuscitate Order

A Do Not Resuscitate (DNR) order is a legally binding document that instructs medical professionals not to perform CPR if a person stops breathing or their heart stops beating. Establishing a DNR involves careful consideration, clear communication with healthcare providers, and proper documentation. This article explains how to navigate the process in the United States, including key steps, options like advance directives and POLST, and how to address common concerns.

What A Do Not Resuscitate Order Means

A DNR order indicates that resuscitation efforts, such as chest compressions, electric shocks, and artificial ventilation, should not be initiated in the event of a life-threatening emergency. It does not affect other medical treatments, comfort care, or life-sustaining therapies that are not resuscitation. DNR decisions are highly personal and should align with medical prognosis, quality of life considerations, and personal values.

Key Differences: DNR, DNAR, And POLST

In the United States, terminology can vary by institution and state. A DNR (Do Not Resuscitate) or DNAR (Do Not Attempt Resuscitation) generally refers to instructions about CPR. A POLST (Physician Orders for Life-Sustaining Treatment) form translates patient preferences into actionable medical orders across care settings. Unlike a standard living will, a POLST is a medical order that accompanies patients across hospitals, clinics, and home care.

Decide And Discuss: Who Should Be Involved

The decision-maker is typically the patient if able, or a legally authorized representative or surrogate if the patient cannot participate. Involving a trusted physician, family members, and sometimes a social worker or palliative care team helps ensure the decision reflects medical realities and personal goals. Clear conversations about prognosis, risks, benefits, and the patient’s values reduce confusion during emergencies.

Steps To Establish A Do Not Resuscitate Order

• Schedule a Conversation With A Physician: Discuss the patient’s current health status, prognosis, and preferences regarding resuscitation. Ensure understanding of what CPR can and cannot achieve in specific medical contexts.
• Consider Related Options: Evaluate whether a Living Will, Durable Power Of Attorney for Healthcare, or POLST form better captures wishes and ensures continuity across care settings.
• Decide On The DNR Status: Choose whether CPR should be pursued in emergencies. Consider how the choice aligns with comfort, independence, and potential outcomes.
• Complete The Documentation: Sign the DNR form or POLST (as required by state) with witnesses or a notary if necessary. Some facilities require specific forms for emergency services.
• Ensure Proper Placement And Sharing: Provide copies to the patient, surrogate, primary care physician, hospital records, and home care providers. Attach to medical charts and advance directives if applicable.
• Communicate The Plan: Inform family members and caregivers about the decision, the location of forms, and how to honor the DNR in different settings (home, hospital, or ambulance).

Where And How DNR Orders Are Recognized

DNR orders are typically recognized within hospitals, clinics, emergency medical services (EMS), and long-term care facilities. Community-based EMS agencies follow state laws and facility policies, so providing a copy of the DNR or POLST helps ensure responders honor the decision. It is essential to verify with local EMS on accepted forms and any required physician signatures or witness attestations.

Common Questions About DNRs

• Can a DNR be changed? Yes. A patient or surrogate can revoke or modify a DNR at any time, and a new decision should be documented and communicated to care teams.
• Will a DNR affect other medical treatments? No. The DNR only addresses resuscitation; other therapies and comfort measures can continue as appropriate.
• What about comfort care? A DNR does not imply withholding comfort-focused care. Pain relief and symptom management should still be provided.
• Is a DNR the same as hospice? No. Hospice focuses on comfort and quality of life for serious, terminal illnesses; a DNR can be an element of ongoing care within various settings, including non-hospice contexts.
• How do I know a DNR is respected? Keep copies with medical records and share information with all healthcare providers. In emergencies, EMS responders will often verify with available documentation or surrogates.

Practical Tips For Families And Caregivers

• Ask About State Variations: DNR and POLST rules differ by state. Confirm the required forms, signatures, and witnessing requirements for your location.
• Plan Ahead: If available, complete advance directives early and review them periodically, especially after health changes or new diagnoses.
• Keep Forms Accessible: Store copies in easily accessible locations, such as a primary care folder, a medical alert kit, and with the patient’s care team.
• Discuss With Family: Ensure all likely decision-makers understand the patient’s wishes to avoid disagreements during crises.

Alternative And Complementary Options

If a formal DNR order does not fully capture preferences, or if continuous alignment with care goals is desired, consider:

• POLST Forms: Convert patient wishes into medical orders active across care settings.
• Living Will: Documents preferences about treatment if the patient cannot express choices later.
• Durable Power Of Attorney For Healthcare: Appoints a surrogate to make medical decisions when the patient cannot.

Important Considerations And Ethical Aspects

Decisions about resuscitation involve medical prognosis, patient autonomy, and family dynamics. Healthcare teams should support informed choices, respect patient values, and reassess decisions as health conditions evolve. Documentation should be clear, current, and easily accessible to all care providers to prevent misinterpretation during emergencies.