What does DNR (Do Not Resuscitate) mean?

Understanding DNR (Do Not Resuscitate)

DNR (Do Not Resuscitate) is a legal order written in a patient's medical file or on a legal form that respects the patient's wishes not to undergo cardiopulmonary resuscitation (CPR) or advanced cardiac life support if their heart or breathing stops. 1, 2

Definition and Purpose

• DNR orders (also called DNAR - Do Not Attempt Resuscitation, or AND - Allow Natural Death) are legal medical orders that document a patient's desire to avoid resuscitation efforts 1, 2
• The term "Allow Natural Death" (AND) is sometimes preferred as it focuses more on what is being done rather than what is being avoided, presenting palliation as the normative default for patients with far advanced cancer 1
• DNR orders require a licensed physician's order to withhold CPR in the hospital setting, based on discussions with the patient or their surrogate 1, 2

Legal Requirements

• DNR orders must be written - oral DNR orders are not acceptable 1, 2
• The attending physician must document the order in accordance with local policy, including:
  • A clear explanation of the rationale for the DNR order 1
  • Documentation of discussions with the patient, surrogate, and family 1
  • Specific instructions regarding which interventions are to be withheld 1, 2

Scope and Limitations

• A DNR order does not automatically preclude other treatments or interventions 1, 2
• DNR orders apply specifically to CPR and do not affect:
  • Administration of parenteral fluids and nutrition 1
  • Oxygen therapy 1
  • Pain management and sedation 1
  • Medication administration including antiarrhythmics or vasopressors 1
  • Other appropriate treatments such as chemotherapy, surgery, antibiotics, and supportive or palliative care 1
• Some patients may choose to accept certain components of resuscitation (like defibrillation and chest compressions) but decline others (such as intubation and mechanical ventilation) 1

Implementation Considerations

• DNR orders should be reviewed periodically according to local protocols, especially if the patient's condition changes 1, 2
• DNR orders should be reviewed before surgery by the anesthesiologist, attending surgeon, and patient or surrogate to determine their applicability during the procedure and immediate postoperative recovery 1
• For patients with special healthcare needs, clear documentation of DNR status should be maintained at home, with the child, and at the child's school or childcare facility 1

Common Pitfalls

• DNR discussions often occur too late in the course of illness, preventing patient participation in the decision 3
• Healthcare providers sometimes inappropriately extrapolate DNR orders to limit other treatments 3
• Lack of clarity in DNR orders can complicate care, especially for patients with special healthcare needs 2
• There is often confusion about the scope of DNR orders among patients, families, and healthcare providers 4

DNR orders represent an important component of advance care planning that respects patient autonomy while preventing non-beneficial interventions at the end of life.