Table of ContentsView AllTable of ContentsWhat DNR MeansTypes of DNR OrdersRulesMaking a DNR Order Work for YouEthical Complications
Table of ContentsView All
View All
Table of Contents
What DNR Means
Types of DNR Orders
Rules
Making a DNR Order Work for You
Ethical Complications
People who are terminally ill often regard a DNR as a graceful way to leave the world on their terms. The details of a DNR are usually discussed at the time of admission to a hospital,nursing facility, or hospice program.
This article explains the meaning of DNR. It details what resuscitation means and the rules governing DNR orders. It also takes a look at how to make a DNR order work for you and the ethical considerations of a DNR.
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DNR means do not resuscitate. Without a DNR, a healthcare provider will take action to revive a person who is unconscious or whose heart or breathing has stopped. A DNR means that the person does not want any life-saving measures.
Resuscitation means to revive or bring back to life. Common resuscitation methods include:
For a patient in cardiac or respiratory arrest, a DNR means thatnoneof these tactics will be used.
Respiratory vs. Cardiac ArrestThe difference between respiratory and cardiac arrest is that respiratory arrest patients still have a beating heart that’s pushing blood around the body. Cardiac arrest patients do not.In both cases, though, a patient is unconscious and not breathing. Respiratory arrest will always lead to cardiac arrest if nothing is done to treat it.
Respiratory vs. Cardiac Arrest
The difference between respiratory and cardiac arrest is that respiratory arrest patients still have a beating heart that’s pushing blood around the body. Cardiac arrest patients do not.In both cases, though, a patient is unconscious and not breathing. Respiratory arrest will always lead to cardiac arrest if nothing is done to treat it.
The difference between respiratory and cardiac arrest is that respiratory arrest patients still have a beating heart that’s pushing blood around the body. Cardiac arrest patients do not.
In both cases, though, a patient is unconscious and not breathing. Respiratory arrest will always lead to cardiac arrest if nothing is done to treat it.
Resuscitation Side Effects
Successful resuscitation can cause significant physical injuries. For example, chest compressions can causebroken ribs, punctured lungs, and possibly a damaged heart.
How Long Does Brain Activity Last After Cardiac Arrest?
Resuscitation Survival Rates
Survival statistics for resuscitation vary widely, partly due to the fact that there are many variables involved, including the age and health status of the patient and whether CPR was performed in a hospital, where emergency support is available.
A 2021 review looked at research published from 2008 onward that focused on the outcome of CPR in patients aged 70 and older following in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA). Survival rates were 28.5% and 11.1%, respectively.
Meanwhile, a Danish study found that 30-day survival rates among nursing home residents who received CPR after OHCA was only 7.7%.
Fatal OutcomesIt’s a painful irony that most people who suffer cardiac arrest are not in a hospital, nursing facility, or hospice program. About 70% of them are at home, and the vast majority (about 90%) die. CPR can double or triple a person’s chance of survival.
Fatal Outcomes
It’s a painful irony that most people who suffer cardiac arrest are not in a hospital, nursing facility, or hospice program. About 70% of them are at home, and the vast majority (about 90%) die. CPR can double or triple a person’s chance of survival.
Healthcare providers may also use the terms no code or allow natural death, which can have different meanings.
No Code
In a hospital, an order to withhold resuscitation is sometimes called a “no code” to distinguish it from a “full code” or “code blue,” both of which mean every effort should be made to resuscitate a patient.
Allow Natural Death
While a DNR order simply states that no attempts should be made to restart breathing or restart the heart if it stops, an allow natural death (AND) order ensures that only comfort measures are taken.
This would include withholding or discontinuing resuscitation, artificial feedings, fluids, and other measures that would prolong a natural death. These orders are typically used in hospice settings or elsewhere for terminally ill patients.
Discussion MattersA study on DNRs and ANDs finds “healthcare providers should address the concept of natural death, provide comprehensive information, and help patients and families to overcome the barriers.”
Discussion Matters
A study on DNRs and ANDs finds “healthcare providers should address the concept of natural death, provide comprehensive information, and help patients and families to overcome the barriers.”
DNR Order Rules
DNR orders are applied according to state laws, which vary from state to state. This can cause confusion.
Some states use standardized forms for DNR orders. If the order is not written on that specific form, it cannot be honored. Other states are less regimented and honor any type of clear DNR order.
In most states, DNR orders are required to follow some of the same general rules in order to be valid. DNR orders must:
Some states allowemergency respondersto follow DNR orders written to other care providers. For instance, in New York State, paramedics and emergency medical technicians (EMTs) are usually allowed to follow DNR orders written for the staff of a nursing home.
Each state is different, and municipalities may differ within each state.
Diligence on DNR OrdersA doctor writes a DNR order only after conferring with the patient (if this is possible), the patient’s appointed representative, or members of the patient’s family.
Diligence on DNR Orders
A doctor writes a DNR order only after conferring with the patient (if this is possible), the patient’s appointed representative, or members of the patient’s family.
If you opt for a DNR order, here’s what you can do to ensure your wishes are respected:
DNR Expresses LimitsA DNR order addresses the issue of CPR, but it does not include instructions for other treatments, such as pain medication or nutrition.
DNR Expresses Limits
A DNR order addresses the issue of CPR, but it does not include instructions for other treatments, such as pain medication or nutrition.
Ethical Complications of DNR Orders
The inconsistent application of DNR orders means some patients may get less than optimal care once providers are aware of the presence of a DNR order.
It’s important to remember that a DNR order is not an order to withhold all treatment. It is only an order not to resuscitate.
The Patient Self Determination Act (PDSA) requires that the wishes of an individual and any existing advance directives be honored in the United States. However, providers do occasionally disregard a DNR; this may be due to due to a lack of communication, for example.
It’s also possible that an existing DNR is honored, but providers fail to confirm with a patient or their representative.
Even the mere mention of a DNR can spawn a wide range of reactions, many of them emotionally charged. Discuss the options with your doctor and your family when everyone is calm and rational—and hopefully sooner rather than later.
Why a Patient Would Choose to Have a DNR OrderPeople with a terminal disease, such as advanced cancer or dementia, may not want CPR. A poor prognosis lowers the likelihood of survival, with a higher risk of heart, lung, and brain damage if resuscitation is attempted. Views on CPR within the medical community are ever-evolving, too, with some professionals revisiting guidelines on how and why resuscitation should be considered.
Why a Patient Would Choose to Have a DNR Order
People with a terminal disease, such as advanced cancer or dementia, may not want CPR. A poor prognosis lowers the likelihood of survival, with a higher risk of heart, lung, and brain damage if resuscitation is attempted. Views on CPR within the medical community are ever-evolving, too, with some professionals revisiting guidelines on how and why resuscitation should be considered.
Summary
A do-not-resuscitate order instructs healthcare providers to refrain from cardiopulmonary resuscitation (CPR) if a patient’s breathing stops or if the patient’s heart stops beating. CPR can also pose a dilemma, but one worth considering, especially in the context of your health (or the health of a loved one). That’s because it requires the heart to be compressed hard and deep enough to pump the blood out of the heart. As such, it can lead tobroken ribs, punctured lungs, and possibly a damaged heart. Those who are resuscitated may also suffer brain damage.
These actions may be too much for someone in frail health. If you wish to explore a DNR order, it’s important to know that the orders vary from state to state. Be sure to investigate the rules in your area before proceeding.
14 SourcesVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.National Library of Medicine: MedlinePlus.Do-not-resuscitate order.Johnson NJ, Caldwell E, Carlbom DJ, et al.The acute respiratory distress syndrome after out-of-hospital cardiac arrest: Incidence, risk factors, and outcomes.Resuscitation. 2019;135:37-44. doi:10.1016/j.resuscitation.2019.01.009Yusufoğlu K, Erdoğan MÖ, Tayfur İ, Afacan MA, Çolak Ş.CPR-related thoracic injuries: comparison of CPR guidelines between 2010 and 2015.Turk J Med Sci. 2018;48(1):24-27. doi:10.3906/sag-1708-59Welbourn C, Efstathiou N.How does the length of cardiopulmonary resuscitation affect brain damage in patients surviving cardiac arrest? A systematic review.Scand J Trauma Resusc Emerg Med. 2018;26(1):77. doi:10.1186/s13049-018-0476-3Zanders R, Druwé P, Van Den Noortgate N, Piers R.The outcome of in- and out-hospital cardiopulmonary arrest in the older population: a scoping review.Eur Geriatr Med. 2021;12(4):695-723. doi:10.1007/s41999-021-00454-yPape M, Rajan S, Hansen SM, et al.Survival rates after out-of-hospital cardiac arrest in nursing homes - a nationwide study.Resuscitation. 2018;125:90-98. doi:10.1016/j.resuscitation.2018.02.004Benjamin EJ, Virani SS, Callaway CW, et al.Heart disease and stroke statistics—2018 update: a report from the American Heart Association.Circulation. 2018;137(12):e67-492. doi:10.1161/CIR.0000000000000558Fan SY, Wang YW, Lin IM.Allow natural death versus do-not-resuscitate: titles, information contents, outcomes, and the considerations related to do-not-resuscitate decision.BMC Palliat Care. 2018 Oct 10;17(1):114. doi:10.1186/s12904-018-0367-4Rai B, Tennyson J, Marshall RT.Retrospective analysis of emergency medical services (EMS) physician medical control calls.West J Emerg Med. 2020;21(3):665-670. doi:10.5811/westjem.2020.1.44943New York State Department of Health.Statewide basic life support adult and pediatric treatment protocols.Chen YY, Gordon NH, Connors AF, et al.Two distinct do-not-resuscitate protocols leaving less to the imagination: an observational study using propensity score matching.BMC Med.2014;12:146. doi:10.1186/s12916-014-0146-xSaitta NM, Hodge SD Jr.What are the consequences of disregarding a “do not resuscitate directive” in the United States?Med Law. 2013;32(4):441-458.Becker C, Künzli N, Perrig S, et al.Code status discussions in medical inpatients: results of a survey of patients and physicians.Swiss Med Wkly. 2020;150:w20194. doi:10.4414/smw.2020.20194Allen MB, Bernacki RE, Gewertz BL, et al.Beyond the do-not-resuscitate order: an expanded approach to decision-making regarding cardiopulmonary resuscitation in older surgical patients.Anesthesiology. 2021;135(5):781-787. doi:10.1097/ALN.0000000000003937
14 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.National Library of Medicine: MedlinePlus.Do-not-resuscitate order.Johnson NJ, Caldwell E, Carlbom DJ, et al.The acute respiratory distress syndrome after out-of-hospital cardiac arrest: Incidence, risk factors, and outcomes.Resuscitation. 2019;135:37-44. doi:10.1016/j.resuscitation.2019.01.009Yusufoğlu K, Erdoğan MÖ, Tayfur İ, Afacan MA, Çolak Ş.CPR-related thoracic injuries: comparison of CPR guidelines between 2010 and 2015.Turk J Med Sci. 2018;48(1):24-27. doi:10.3906/sag-1708-59Welbourn C, Efstathiou N.How does the length of cardiopulmonary resuscitation affect brain damage in patients surviving cardiac arrest? A systematic review.Scand J Trauma Resusc Emerg Med. 2018;26(1):77. doi:10.1186/s13049-018-0476-3Zanders R, Druwé P, Van Den Noortgate N, Piers R.The outcome of in- and out-hospital cardiopulmonary arrest in the older population: a scoping review.Eur Geriatr Med. 2021;12(4):695-723. doi:10.1007/s41999-021-00454-yPape M, Rajan S, Hansen SM, et al.Survival rates after out-of-hospital cardiac arrest in nursing homes - a nationwide study.Resuscitation. 2018;125:90-98. doi:10.1016/j.resuscitation.2018.02.004Benjamin EJ, Virani SS, Callaway CW, et al.Heart disease and stroke statistics—2018 update: a report from the American Heart Association.Circulation. 2018;137(12):e67-492. doi:10.1161/CIR.0000000000000558Fan SY, Wang YW, Lin IM.Allow natural death versus do-not-resuscitate: titles, information contents, outcomes, and the considerations related to do-not-resuscitate decision.BMC Palliat Care. 2018 Oct 10;17(1):114. doi:10.1186/s12904-018-0367-4Rai B, Tennyson J, Marshall RT.Retrospective analysis of emergency medical services (EMS) physician medical control calls.West J Emerg Med. 2020;21(3):665-670. doi:10.5811/westjem.2020.1.44943New York State Department of Health.Statewide basic life support adult and pediatric treatment protocols.Chen YY, Gordon NH, Connors AF, et al.Two distinct do-not-resuscitate protocols leaving less to the imagination: an observational study using propensity score matching.BMC Med.2014;12:146. doi:10.1186/s12916-014-0146-xSaitta NM, Hodge SD Jr.What are the consequences of disregarding a “do not resuscitate directive” in the United States?Med Law. 2013;32(4):441-458.Becker C, Künzli N, Perrig S, et al.Code status discussions in medical inpatients: results of a survey of patients and physicians.Swiss Med Wkly. 2020;150:w20194. doi:10.4414/smw.2020.20194Allen MB, Bernacki RE, Gewertz BL, et al.Beyond the do-not-resuscitate order: an expanded approach to decision-making regarding cardiopulmonary resuscitation in older surgical patients.Anesthesiology. 2021;135(5):781-787. doi:10.1097/ALN.0000000000003937
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
National Library of Medicine: MedlinePlus.Do-not-resuscitate order.Johnson NJ, Caldwell E, Carlbom DJ, et al.The acute respiratory distress syndrome after out-of-hospital cardiac arrest: Incidence, risk factors, and outcomes.Resuscitation. 2019;135:37-44. doi:10.1016/j.resuscitation.2019.01.009Yusufoğlu K, Erdoğan MÖ, Tayfur İ, Afacan MA, Çolak Ş.CPR-related thoracic injuries: comparison of CPR guidelines between 2010 and 2015.Turk J Med Sci. 2018;48(1):24-27. doi:10.3906/sag-1708-59Welbourn C, Efstathiou N.How does the length of cardiopulmonary resuscitation affect brain damage in patients surviving cardiac arrest? A systematic review.Scand J Trauma Resusc Emerg Med. 2018;26(1):77. doi:10.1186/s13049-018-0476-3Zanders R, Druwé P, Van Den Noortgate N, Piers R.The outcome of in- and out-hospital cardiopulmonary arrest in the older population: a scoping review.Eur Geriatr Med. 2021;12(4):695-723. doi:10.1007/s41999-021-00454-yPape M, Rajan S, Hansen SM, et al.Survival rates after out-of-hospital cardiac arrest in nursing homes - a nationwide study.Resuscitation. 2018;125:90-98. doi:10.1016/j.resuscitation.2018.02.004Benjamin EJ, Virani SS, Callaway CW, et al.Heart disease and stroke statistics—2018 update: a report from the American Heart Association.Circulation. 2018;137(12):e67-492. doi:10.1161/CIR.0000000000000558Fan SY, Wang YW, Lin IM.Allow natural death versus do-not-resuscitate: titles, information contents, outcomes, and the considerations related to do-not-resuscitate decision.BMC Palliat Care. 2018 Oct 10;17(1):114. doi:10.1186/s12904-018-0367-4Rai B, Tennyson J, Marshall RT.Retrospective analysis of emergency medical services (EMS) physician medical control calls.West J Emerg Med. 2020;21(3):665-670. doi:10.5811/westjem.2020.1.44943New York State Department of Health.Statewide basic life support adult and pediatric treatment protocols.Chen YY, Gordon NH, Connors AF, et al.Two distinct do-not-resuscitate protocols leaving less to the imagination: an observational study using propensity score matching.BMC Med.2014;12:146. doi:10.1186/s12916-014-0146-xSaitta NM, Hodge SD Jr.What are the consequences of disregarding a “do not resuscitate directive” in the United States?Med Law. 2013;32(4):441-458.Becker C, Künzli N, Perrig S, et al.Code status discussions in medical inpatients: results of a survey of patients and physicians.Swiss Med Wkly. 2020;150:w20194. doi:10.4414/smw.2020.20194Allen MB, Bernacki RE, Gewertz BL, et al.Beyond the do-not-resuscitate order: an expanded approach to decision-making regarding cardiopulmonary resuscitation in older surgical patients.Anesthesiology. 2021;135(5):781-787. doi:10.1097/ALN.0000000000003937
National Library of Medicine: MedlinePlus.Do-not-resuscitate order.
Johnson NJ, Caldwell E, Carlbom DJ, et al.The acute respiratory distress syndrome after out-of-hospital cardiac arrest: Incidence, risk factors, and outcomes.Resuscitation. 2019;135:37-44. doi:10.1016/j.resuscitation.2019.01.009
Yusufoğlu K, Erdoğan MÖ, Tayfur İ, Afacan MA, Çolak Ş.CPR-related thoracic injuries: comparison of CPR guidelines between 2010 and 2015.Turk J Med Sci. 2018;48(1):24-27. doi:10.3906/sag-1708-59
Welbourn C, Efstathiou N.How does the length of cardiopulmonary resuscitation affect brain damage in patients surviving cardiac arrest? A systematic review.Scand J Trauma Resusc Emerg Med. 2018;26(1):77. doi:10.1186/s13049-018-0476-3
Zanders R, Druwé P, Van Den Noortgate N, Piers R.The outcome of in- and out-hospital cardiopulmonary arrest in the older population: a scoping review.Eur Geriatr Med. 2021;12(4):695-723. doi:10.1007/s41999-021-00454-y
Pape M, Rajan S, Hansen SM, et al.Survival rates after out-of-hospital cardiac arrest in nursing homes - a nationwide study.Resuscitation. 2018;125:90-98. doi:10.1016/j.resuscitation.2018.02.004
Benjamin EJ, Virani SS, Callaway CW, et al.Heart disease and stroke statistics—2018 update: a report from the American Heart Association.Circulation. 2018;137(12):e67-492. doi:10.1161/CIR.0000000000000558
Fan SY, Wang YW, Lin IM.Allow natural death versus do-not-resuscitate: titles, information contents, outcomes, and the considerations related to do-not-resuscitate decision.BMC Palliat Care. 2018 Oct 10;17(1):114. doi:10.1186/s12904-018-0367-4
Rai B, Tennyson J, Marshall RT.Retrospective analysis of emergency medical services (EMS) physician medical control calls.West J Emerg Med. 2020;21(3):665-670. doi:10.5811/westjem.2020.1.44943
New York State Department of Health.Statewide basic life support adult and pediatric treatment protocols.
Chen YY, Gordon NH, Connors AF, et al.Two distinct do-not-resuscitate protocols leaving less to the imagination: an observational study using propensity score matching.BMC Med.2014;12:146. doi:10.1186/s12916-014-0146-x
Saitta NM, Hodge SD Jr.What are the consequences of disregarding a “do not resuscitate directive” in the United States?Med Law. 2013;32(4):441-458.
Becker C, Künzli N, Perrig S, et al.Code status discussions in medical inpatients: results of a survey of patients and physicians.Swiss Med Wkly. 2020;150:w20194. doi:10.4414/smw.2020.20194
Allen MB, Bernacki RE, Gewertz BL, et al.Beyond the do-not-resuscitate order: an expanded approach to decision-making regarding cardiopulmonary resuscitation in older surgical patients.Anesthesiology. 2021;135(5):781-787. doi:10.1097/ALN.0000000000003937
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