Making Decisions: CPR & DNR Orders

October 25, 2010
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What do CPR and DNR orders mean?
CPR – cardiopulmonary resuscitation — refers to the medical procedures used to restart a patient’s heart and breathing when the patient suffers heart failure. CPR may involve simple efforts such as mouth-to-mouth resuscitation and external chest compression. Advanced CPR may involve electric shock, insertion of a tube to open the patient’s airway, injection of medication into the heart and in extreme cases, open chest heart massage.

A do-not-resuscitate (DNR) order tells medical professionals not to perform CPR. This means that doctors, nurses and emergency medical personnel will not attempt emergency CPR if the patient’s breathing or heartbeat stops.

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 resuscitate 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.

Why are DNR orders issued?
CPR, when successful, restores heartbeat and breathing and allows a patient to resume his/ her previous lifestyle. The success of CPR depends on the patient’s overall medical condition. Age alone does not determine whether CPR will be successful, although illnesses and frailties that go along with age often make CPR less successful.

When patients are seriously ill or terminally ill, CPR may not work or may only partially work, leaving the patient brain-damaged or in a worse medical state than before the heart stopped. In these cases, some patients prefer to be cared for without aggressive efforts at resuscitation.

Can I request a DNR order?
Yes. All adult patients can request a DNR order. If you are sick and unable to tell your doctor that you want a DNR order written, a family member or close friend can decide for you.

Are DNR orders ethically acceptable?
It is widely recognized by health care professionals, clergy, lawyers and others that DNR orders are medically and ethically appropriate under certain circumstances. For some patients, CPR offers more burdens than benefits, and may be against the patient’s wishes.

Is my consent required for a DNR order?
Your doctor must speak to you before entering a DNR order if you are able to decide, unless your doctor believes that discussing CPR with you would cause you severe harm. In an emergency, it is assumed that all patients would consent to CPR. However, if a doctor decides that CPR will not work, it is not provided.

How can I make my wishes about DNR known?
During hospitalization, an adult patient may consent to a DNR order orally or in writing, if two adult witnesses are present. When consent is given orally, one of the witnesses must be a physician affiliated with the hospital. Prior to hospitalization, consent must be in writing in the presence of two adult witnesses. In addition, the Health Care Proxy Law allows you to appoint someone you trust to make decisions about CPR and other treatments if you become unable to decide for yourself.

Before deciding about CPR, you should speak with your doctor about your overall health and the benefits and burdens CPR would provide for you. A full and early discussion between you and your doctor will assure that your wishes will be known.

If I request a DNR order, must my doctor honor my wishes?
If you don’t want CPR and you request a DNR order, your doctor must follow your wishes or transfer your care to another doctor who will follow your wishes; or begin a process to settle the dispute if you are in a hospital or nursing home.

If the dispute is not resolved within 72 hours, your doctor must enter the order or transfer you to the care of another doctor.

If I am not able to decide about CPR for myself, who will decide?
First, two doctors must determine that you are unable to decide about CPR. You will be told of this determination and have the right to object.

If you become unable to decide about CPR, and you did not tell your doctor or others about your wishes in advance, a DNR order can be written with the consent of the person highest on the following list:

– your health care agent — the person chosen by you to make health care decisions under New York’s Health Care Proxy Law (if you have appointed one);

– a court appointed guardian (if there is one);

– your closest relative (spouse, child, parent, sibling);

– a close friend.

How can I select someone to decide for me?
The Health Care Proxy Law allows adults to select someone they trust to make health care decisions for them when they are no longer able to do so themselves, including decisions about CPR. You can name someone by filling out a health care proxy form.

Under what circumstances can a family member or close friend decide that a DNR order should be written?
A family member or close friend can consent to a DNR order only when you are unable to decide for yourself and you have not appointed a health care agent to decide for you. Your family member or friend can consent to a DNR order when:

– you are terminally ill; or

– you are permanently unconscious; or

– CPR will not work (would be medically futile); or

– CPR would impose an extraordinary burden on you given your medical condition and the expected outcome of CPR.

Anyone deciding for you must base the decision on your wishes, including your religious and moral beliefs, or if your wishes are not known, on your best interests.

What if members of my family disagree?
In a hospital or nursing home, your family can ask that the disagreement be mediated. Your doctor can request mediation if he or she is aware of any disagreement among your family members.

What if I lose the ability to make decisions about CPR and do not have anyone who can decide for me?
A DNR order can be written if two doctors decide that CPR would not work or if a court approves of the DNR order. It would be best if you discussed your wishes about CPR with your doctor in advance.

What happens if I change my mind after a DNR order has been written?
You or anyone who consents to a DNR order for you can revoke consent for the order by telling your doctor, nurses or others of the decision.

If I am at home with a nonhospital DNR order, what happens if a family member or friend panics and calls an ambulance to resuscitate me?
If you have a nonhospital DNR order and family members show it to emergency personnel, they will not try to resuscitate you or take you to a hospital emergency room for CPR.

What happens to my DNR order if I am transferred from a hospital or nursing home to home care?
The order issued for you in a hospital or nursing home will not apply at home. You, your health care agent or family member must specifically consent to a nonhospital DNR order. If you leave a hospital or nursing home without a nonhospital DNR order, a DNR order can be issued by a doctor for you at home.

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