Do Not Resuscitate (DNR)


Article Author:
Josephine Vranick


Article Editor:
Monica Stanton


Editors In Chief:
Bette Bogdan
Lori Kerley
Robin Geiger


Managing Editors:
Frank Smeeks
Scott Dulebohn
Erin Hughes
Pritesh Sheth
Mark Pellegrini
James Hughes
Richard Ciresi
Phillip Hynes


Updated:
10/27/2018 12:31:32 PM

Introduction

End-of-Life discussions or advance care planning (ACP) with family and primary care providers can be challenging, but they are necessary to maintain patient autonomy and reach a well-informed decision.  Studies have shown that less than 30% of survey participants have an advance directive. Most individuals with advance directives share similar characteristics: chronic illness, regular access to healthcare, higher income, higher education, and older age. Racial and ethnic disparities also have accounted for a lower percentage of advance directives, particularly among non-white respondents.  

Function

Advance directives may vary by state, but all are designed to outline care preferences in the event one becomes incapacitated. Initiating a discussion and implementation of an advance directive should include patient care preference regarding code status or cardiopulmonary resuscitation. Advance directives are legal documents but are not medical orders. Though many advance directives include preferences pertaining to cardiopulmonary resuscitation, they are not equivalent to Do-Not-Resuscitate (DNR) or Do-Not-Intubate (DNI) orders. Furthermore, some directives clearly specify exactly what is wanted for a given situation, while others, as noted above, remain vague.  It is important to specifically illicit patient preference regarding DNR and DNI during an advance directive discussion. According to one study, it may be beneficial to start with two simple questions:  “If you cannot or choose not to participate in health care decisions, with whom should we speak?" and  "If you cannot or choose not to participate in the decision-making, what should we consider when making a decision about your care?” Though these questions may help initiate a dialogue, they do not specifically address patient care preferences regarding DNR and DNI, and further detailed discussions are needed. For select hospitalized patients without advance directives or DNR/DNI orders, physicians may find the discussion difficult but necessary.  Unfortunately, there may exist a notion that do-not-resuscitate equates to do-not-treat.  It is paramount that all parties involve understand do-not-resuscitate does not mean all treatments are discontinued and standard of care is not hindered by a DNR order. Gauging a patient’s or proxy’s understanding of the current condition and expectations can be a useful introduction to the discussion. The questions noted above can also be used to guide the physician but do not specifically address DNR or DNI preferences. Physicians educated in the skills necessary to have the discussions have led to an increase in patient preferences at end-of-life. Despite the evidence, however, junior physicians report little formal education regarding palliative or end-of-life issues and have cited hospital culture as a deterrent to engaging and learning more about the subject. Minimal training in end-of-life discussions and exposure to palliative care patients at the medical school level is another barrier to physician comfort in end-of-life care. Regardless, earlier and more complete discussions regarding a range of care preferences should be undertaken, and early involvement of a palliative care team may lead to better understanding of a DNR order. A multidisciplinary approach can further solidify the process by utilizing nursing and case management resources.  Once patient care preferences are decided, an order in the form of a legal document is added to the medical record. It is important to note that different hospitals and States may use different documents to indicate DNR and DNI orders and include: Medical Orders for Scope of Treatment (MOST), Medical Orders for Life Sustaining Treatment (MOLST), Physician Orders for Scope of Treatment (POST) and Physician Orders for Life Sustaining Treatment (POLST).  Unlike an advance directive, patient wishes including DNR and DNI preferences are conveyed as a medical order on a MOLST or POLST form.

Issues of Concern

Particularly in the office setting, there remain barriers to completing and implementing advance directives that are often physician and patient related. Physicians have sited discomfort with the topic and limitations on time and reimbursement as reasons to forgo the discussion. Patients identify fear, lack of knowledge, and cultural traditions as deterrents. Sadly, a common reason identified by both physicians and patients is waiting for the other party to initiate the discussion. Even when advance directives are made, there may still be barriers to implementation including vague language, proxy issues, and accessibility of the advanced directive. Physicians should encourage patients to avoid vague terminology and be explicit in care preferences and procedures. Including the health care proxy in the advance directive discussions ensures that the proxy is aware of the patient’s wishes and can further clarify any vague language or questions regarding patient care preferences. Finally, advance directives should be part of the medical record and readily available to the physician, proxy, and requested family members. Given the challenges cited, several studies have identified interventions that may increase advance directive completion rates. The most successful interventions are interactive and include repeated conversations over time. Group-based interventions that stimulate discussion and generate additional questions also have been successful. Several studies have produced good recommendations including a protocol-driven negotiation on goals of care. This protocol includes identifying the proper setting, assessing patient and proxy’s understanding and expectations and suggesting more realistic goals. Another approach for primary care physicians to utilize when initiating the discussion has been proposed.  This approach can occur at multiple stages and involves interactive advance directive discussions.  The stage to initiate the discussion is during a routine exam. There is no defined age to initiate the discussion, but it is generally recommended in patients 50 to 65 years of age. Advance directives should be reintroduced at the diagnosis of a progressive chronic disease and again following concern of increased frailty or dependence. Higher completion rates have been seen with mailing the forms to the patient prior to the initial discussion. These approaches can be used together or in isolation as there is no set guidelines on end-of-life issues and DNR discussions.

Clinical Significance

The importance of advance care planning cannot be emphasized enough. Though a challenging subject for both physicians and patients it is necessary to ensure patient autonomy and implement care preferences when patients are incapacitated. It is a proactive and continual process that may need to be revisited based on any changes in a patient’s medical condition. Currently, there are no set guidelines to instruct physicians, but the evidence does exist to guide conversations and improve implementation. 


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE courses, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Do Not Resuscitate (DNR) - Questions

Take a quiz of the questions on this article.

Take Quiz
After consultation with the next of kin, a patient who is in a coma from liver failure is disconnected from life support. Which document was executed by the health care staff?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Select the choice most TRUE of DNR:



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient is admitted for hospice care. Which of the following should be requested?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which choice is TRUE of Advanced Directives and the need for written "Do not Resuscitate Orders (DNRs)"



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Select the choice which is true of "Do Not Resuscitate".



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient has a "do not resuscitate" order. Which action is least appropriate?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Do Not Resuscitate (DNR) - References

References

Improving completion of advance directives in the primary care setting: a randomized controlled trial., Heiman H,Bates DW,Fairchild D,Shaykevich S,Lehmann LS,, The American journal of medicine, 2004 Sep 1     [PubMed]
Physician perspectives on resuscitation status and DNR order in elderly cancer patients., Trivedi S,, Reports of practical oncology and radiotherapy : journal of Greatpoland Cancer Center in Poznan and Polish Society of Radiation Oncology, 2013 Jan 16     [PubMed]
Why are newly qualified doctors unprepared to care for patients at the end of life?, Gibbins J,McCoubrie R,Forbes K,, Medical education, 2011 Apr     [PubMed]
An advance directive in two questions., Mahon MM,, Journal of pain and symptom management, 2011 Apr     [PubMed]
Implementing advance directives in office practice., Spoelhof GD,Elliott B,, American family physician, 2012 Mar 1     [PubMed]
Care Planning for Inpatients Referred for Palliative Care Consultation., Bischoff K,O'Riordan DL,Marks AK,Sudore R,Pantilat SZ,, JAMA internal medicine, 2017 Nov 20     [PubMed]
A clinical framework for improving the advance care planning process: start with patients' self-identified barriers., Schickedanz AD,Schillinger D,Landefeld CS,Knight SJ,Williams BA,Sudore RL,, Journal of the American Geriatrics Society, 2009 Jan     [PubMed]
Engagement in multiple steps of the advance care planning process: a descriptive study of diverse older adults., Sudore RL,Schickedanz AD,Landefeld CS,Williams BA,Lindquist K,Pantilat SZ,Schillinger D,, Journal of the American Geriatrics Society, 2008 Jun     [PubMed]
Timing of Advance Directive Completion and Relationship to Care Preferences., Enguidanos S,Ailshire J,, Journal of pain and symptom management, 2017 Jan     [PubMed]
Racial and ethnic differences in advance care planning: identifying subgroup patterns and obstacles., Carr D,, Journal of aging and health, 2012 Sep     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Nurse-Professional and Ethics. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Nurse-Professional and Ethics, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Nurse-Professional and Ethics, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Nurse-Professional and Ethics. When it is time for the Nurse-Professional and Ethics board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Nurse-Professional and Ethics.